The Unusual Suspects

Often-Overlooked Muscles

By Joseph E. Muscolino, DC

There are more than 100 muscles in the human body, yet it is interesting to see how often the same few muscles are discussed, written about, and assessed as the causes of our clients’ problems. I like to describe these muscles as the usual suspects. When a client has pain in the gluteal region, we look for it to be the piriformis. If the pain is in the anterior hip, the psoas major is first on our radar. If there is pain in the back of the neck, it must be the upper trapezius. But what about all the other muscles in the body?
I am not trying to say that the usual suspect muscles are not important. They are. Because of their unique role in movement and stabilization patterns, they probably are more important on average than any one of their neighbors; that is why they have earned the status of being the usual suspects. A usual suspect is not always the guilty party, however. Sometimes it is an unusual suspect, a lesser-known muscle, that is the underlying cause of our client’s pain and dysfunction pattern.
Following are examples of some of these lesser-known unusual suspect muscles that I believe are worthy of our attention. For each muscle, we will review its attachments and actions, how to palpate and stretch it, and then discuss a brief case study of a client for whom this muscle was the key to unlocking their condition and restoring their health. An unusual suspect muscle may not often prove to be the cause of our client’s condition; but when it is, our awareness and knowledge of the muscle, along with our willingness to look for and assess it, can make all the difference, not only in our client’s health, but also in the success of our practice.

Looking in the Right Place
There is a corny but apt joke about a mother who comes home to find her 12-year-old son on his hands and knees in the dining room, seemingly searching for something. When she asks him if he lost something, he says he lost a quarter. She asks him if he lost it in the dining room, and he answers no; he lost it in the living room. A bit perplexed, she asks him why he is looking in the dining room. He responds, “The light’s better in here.”
This may seem like a silly story, but there is a lesson to be learned here. If we are not looking in the right place, we will never find what we are looking for. We shouldn’t look just where it is easy to look, where the light is better, so to speak; rather, we also need to look in the more obscure, less well-lit places. If we only check the usual suspect muscles, we will never discover how involved and important some of the other, lesser-known, unusual suspect muscles are.

Unusual Suspect #1
Palmar Interossei
Attachments and Actions
The palmar interossei (PI) are a group of three intrinsic hand muscles that, as their name implies, are located between (metacarpal) bones in the palm of the hand (Image 1). Each one crosses the metacarpophalangeal (MCP) joint to attach distally onto the proximal phalanx of a finger on the side of the phalanx that is oriented toward the middle finger. For this reason, each one pulls its respective finger toward the middle finger, which is the reference line for abduction/adduction of the fingers; hence the PI adduct fingers at the MCP joints. They are named #1, #2, and #3, from radial to ulnar. PI #1 attaches from the second metacarpal to the index finger; PI #2 attaches from the fourth metacarpal to the ring finger; and PI #3 attaches from the fifth metacarpal to the little finger.

Palpation Assessment
Although the PI are a bit deep, they are easy to palpate and assess. To palpate and discern PI #1, simply place your palpating finger pads between the second and third metacarpals on the palmar side, with pressure oriented toward the second metacarpal, and ask the client to adduct the index finger toward the middle finger against the resistance of a pen or marker that is placed between the two fingers. The first PI will clearly be felt to engage (Image 2). Palpate the entirety of the muscle as the client gently contracts and relaxes it. Once located, moderate to deeper pressure can be applied to work the muscle.
The PI muscles perform adduction of their respective fingers. In addition, because they cross the MCP joints slightly anteriorly, they can also flex the fingers at the MCP joints. Therefore, to stretch the PI, the index, ring, and little fingers need to be abducted (away from the middle finger) and extended at the MCP joints (Image 3).

Case Study: Palmar Interossei
“Carrie” was a 30-year-old yoga instructor who developed pain in the palm of her left hand. There was no precipitating trauma; the pain began insidiously and gradually increased until she could no longer bear any weight on her hand. Poses such as downward-facing dog became impossible. Before coming to my office, Carrie consulted three health professionals—a massage therapist, a chiropractor, and an orthopedic surgeon specializing in hand surgery. The massage therapist told her that trigger points in her left shoulder were the cause of the pain. The chiropractor told her that neck joint subluxations (dysfunctions) were the cause. And the orthopedic surgeon ordered an X-ray and told her that the saddle (first carpometacarpal) joint of the thumb was too lax and surgery would be needed to stabilize the joint and alleviate the pain. Soft-tissue manipulation to the shoulder region by the massage therapist and joint manipulation (adjusting) of the neck by the chiropractor did not help to diminish her hand pain. And Carrie opted to not have the surgery recommended by the orthopedic surgeon.     
Carrie then presented to me. After I exhausted all the usual suspects, spending well over an hour on history and exam, I finally arrived at her hand, where I palpated and found a hypertonic PI #1 muscle, that, when pressed into, immediately reproduced her characteristic pain. Carrie had a spasm of her first PI muscle. No fancy referral patterns or pinched nerves were involved. She had a simple tight muscle in her hand that none of the other professionals had even tried to look for, even though it was exactly at the site of the pain that she was experiencing. Moist heat, soft-tissue manipulation, and stretching fully resolved her condition in only a few sessions. Who was the overlooked unusual suspect? The first palmar interosseus muscle! 

Unusual Suspect #2
Flexor Pollicis Longus

Attachments and Actions
The flexor pollicis longus is a muscle of the anterior forearm and hand. Its principal attachments are from the anterior surface of the radius to the anterior surface of the distal phalanx of the thumb. It usually also has a small attachment to the medial epicondyle of the humerus (Image 4A). The flexor pollicis longus crosses the elbow, wrist, and thumb joints anteriorly; therefore, it flexes the forearm at the elbow joint, the hand at the wrist joint, and the thumb at the carpometacarpal, metacarpophalangeal, and interphalangeal joints. Because of its medial to lateral direction from proximal to distal, it can also weakly pronate the forearm at the radioulnar joints.
It is important to note that the flexor pollicis longus is one of nine tendons that travel through the carpal tunnel. The other eight tendons are the four tendons of the flexor digitorum superficialis and the four tendons of the flexor digitorum profundus (Image 4B).  

Palpation Assessment
Although the flexor pollicis longus is in the deep layer of the anterior forearm musculature, it is actually quite easy to palpate and assess for the majority of its course. To palpate this muscle, simply place your palpating finger pads on the radial side of the anterior, distal forearm and ask the client to flex the distal phalanx of the thumb at the interphalangeal joint. To properly discern the flexor pollicis longus from other nearby muscles of the thumb, it is important for the client to isolate this action as best as possible (Image 5, page 56). No other muscle flexes the distal phalanx of the thumb, so any muscle that contracts during this motion should be the flexor pollicis longus. Palpate as much of the muscle as possible as the client gently contracts and relaxes it. The flexor pollicis longus can usually be easily palpated and discerned proximally toward the elbow joint to about halfway up the forearm. Once located, moderate to deeper pressure can be applied to work the muscle.
Because the flexor pollicis longus flexes the elbow, wrist, and thumb joints, it is stretched by extending the elbow, wrist, and thumb. Because of its ability to pronate the forearm, the stretch position should include full forearm supination as well (Image 6).

Case Study: Flexor Pollicis Longus
“Julie” was a 25-year-old massage therapist who was experiencing tingling and pain into the median nerve distribution of her right hand, specifically the anterior side of the thumb and index finger. She attributed her symptoms to the physical stress of performing too many massages at work. As she continued to massage, the pain gradually increased until she consistently experienced moderate to marked pain when working. On physical examination, she tested positive for all three carpal tunnel syndrome tests—Phalen’s test, Prayer test, and Tinel’s sign at the anterior wrist—so there was no doubt she was experiencing carpal tunnel syndrome.
The question was whether rest and working on the muscles whose tendons traveled through the carpal tunnel would be sufficient for her to heal. I advised her to stop work for two to four weeks, use ice each day, take over-the-counter anti-inflammatories, and come in two times per week for soft-tissue manipulation and gentle stretching to musculature of the anterior forearm. This work was aimed primarily at the flexors digitorum superficialis and profundus, and flexor pollicis longus. However, it was work on the flexor pollicis longus that seemed to most directly reproduce her characteristic pain pattern, referring pain into the wrist and anterior hand as the work was done. More importantly, it was the flexor pollicis longus work that provided lasting relief after the therapy was done. Deep stroking massage was performed on the myofascial trigger points that were located in the belly of the muscle, and transverse friction was done to break up fascial adhesions that were binding the muscle and its tendon to adjacent tissues and impeding proper function. After the soft-tissue manipulation, stretching was performed.
Although soft-tissue work was also performed on other musculature of the right upper extremity and neck, it was the work performed on the flexor pollicis longus that proved to be most effective. After a few weeks, Julie began working again, and with continued care, as well as attention to proper body mechanics, she was able to gradually build back up to working full time, pain-free over the next few months.

Unusual Suspect #3 Quadratus Femoris
Attachments and Actions
The quadratus femoris is a muscle of the gluteal/hip joint region. It attaches from the lateral border of the ischial tuberosity to the intertrochanteric crest of the femur, between the greater and lesser trochanters (Image 7). The quadratus femoris crosses the hip joint posteriorly with a horizontal direction to its fibers; therefore, it laterally (externally) rotates the thigh at the hip joint. Indeed, along with the piriformis, it is one of the six members of the deep lateral rotator group.

Palpation Assessment
Although the quadratus femoris is deep to the gluteus maximus, it is usually easily palpated and discerned from adjacent musculature. To palpate the quadratus femoris, first find the inferior aspect of the ischial tuberosity. Follow the ischial tuberosity to its lateral border by maintaining pressure against the bone as you move laterally along it. Once the lateral border has been reached, drop immediately lateral to it and you will be on the quadratus femoris. To engage the muscle to confirm you are on it, have the client try to laterally rotate the thigh at the hip joint against your gentle to moderate resistance. This is accomplished by asking the client to try to push the (lower) leg medially against the resistance of your hand (Image 8). Palpate the entirety of the muscle as the client gently contracts and relaxes it. Once located, moderate to deeper pressure can be applied to work the muscle.
Note: The sciatic nerve usually passes superficial to the quadratus femoris immediately lateral to the ischial tuberosity. If the sciatic nerve is contacted, move your finger pads slightly lateral to avoid pressure on the nerve.
The quadratus femoris is a lateral rotator at the hip joint, but if the thigh is first flexed to 90 degrees, it becomes a horizontal abductor so it can be stretched with horizontal adduction as seen in Image 9.

Case Study: Quadratus Femoris
“Belinda” presented with pain in her right gluteal region that had begun the day before. She said she had been stretching her hip joint fairly vigorously when she first felt a sharp pain occur in the area. Concerned she might have injured herself, she decided to seek care immediately and presented to my office the day after the pain began. Upon palpation examination, I went for the usual suspect, the piriformis; but her piriformis was healthy and palpation of it did not reproduce any pain or discomfort. However, as I continued to palpate inferior and lateral to the piriformis, I came upon a trigger point in the quadratus femoris that, when pressed, reproduced Belinda’s characteristic pain pattern. Because Belinda came in so quickly after the onset of the problem, one session of moist heat, deep stroking massage, and stretching was sufficient to entirely resolve the trigger point and eliminate all her pain and discomfort.

Unusual Suspect #4 Coccygeus and Levator Ani
Attachments and Actions
The coccygeus and levator ani are pelvic floor muscles located between the sacrum and coccyx medially and the pelvic bone laterally (Image 10). As pelvic floor muscles, they are important toward maintaining the stability of the abdominopelvic cavity, and therefore the core of the body. But what is often overlooked is that via their attachments onto the sacrum and coccyx, they can also function to stabilize the sacroiliac joint. The coccygeus specifically attaches from the sacrum (and coccyx) to the pelvic bone, and therefore directly affects sacroiliac function. For this reason, the coccygeus and levator ani should be assessed in every client who presents with sacroiliac pain or dysfunction.

Palpation Assessment
The coccygeus and levator ani are located fairly deep, but can usually be easily palpated. Two methods can be used to palpate these muscles. One method is to first locate the coccygeus by locating the piriformis and then dropping inferiorly, maintaining pressure against the sacrum, until the coccygeus is reached. Once the coccygeus has been found, palpate inferior to it for the levator ani. The other method is to instead first locate the levator ani by following from the inferior aspect of the ischial tuberosity to its medial side, then dropping immediately medial to its medial border onto the levator ani. From there, palpate superior to the levator ani for the coccygeus, always hugging close against the coccyx and then the sacrum. It is not easy to ask the client to engage these muscles, so they are usually palpated while at rest. Once located, they are assessed.
When palpating these muscles, it is important to be aware of two prominent ligaments located superficially. They are the sacrotuberous and sacrospinous ligaments (Image 11). The coccygeus can be discerned from the sacrotuberous ligament by noting the different directions of their fibers. It is essentially not possible to discern the coccygeus from the sacrospinous ligament. They run in an identical direction and attach into each other. For this reason, they can be considered to be one myofascial unit.
Note: Many therapists are hesitant to palpate and work these muscles because of their proximity to the anus. However, their dual function as pelvic floor and sacroiliac joint stabilization muscles makes them extremely valuable musculature that should not be skipped. Certainly, given the concern for modesty, verbal consent should be first attained; communicate clearly with your client regarding the work, the process, and the goal. Careful draping, or working the muscles through draping, should be practiced. Further, these muscles can be worked ipsilaterally or contralaterally, whichever is more comfortable for the client.
It is challenging to stretch the coccygeus and levator ani musculature. If the thigh is abducted, this may place a small force that separates the pelvic bone from the sacrum/coccyx, thereby slightly stretching these muscles.

Case Study: Coccygeus and Levator Ani
“Janice” was a 35-year-old woman who presented with left gluteal pain. She reported that she had been walking down a staircase and misjudged the number of steps. As a result, she landed hard on her left foot at the bottom of the stairs and felt a jolt of pain shoot up into her left gluteal region. This pain then persisted with each step she took on her left side. She came in for treatment a few days later, complaining of persistent pain near her “tailbone.” During the palpation exam, I first assessed the piriformis, which was healthy. I then proceeded to assess the quadratus femoris and other deep lateral rotators, which were also healthy and when pressed did not reproduce any pain or discomfort. As I continued to search for the cause of the pain, Janice kept indicating her pain was more medial. When I palpated directly lateral to the coccyx, I clearly felt a trigger point that reproduced her characteristic pain pattern. Four treatments of moist heat and deep massage were successful at resolving her condition.

Chronicity, not Severity
Case studies are presented to demonstrate how appropriate assessment and treatment can be successful toward resolving a client’s problem. For this reason, case studies are often success stories in which one or a few treatments help to resolve the client’s condition. But as any long-practicing therapist knows, most of our clients’ conditions are not miraculously cured with a session or two.
Many of the case studies presented here were as successful as they were because the client chose to seek care very soon after the condition began. An important principle of manual and movement therapy is that our biggest enemy is not the severity of the condition, but rather the chronicity; in other words, how long the condition has been present.
The longer the client waits before seeking care, the more the condition becomes entrenched, with patterns of nervous system engagement becoming more facilitated and fibrous adhesions building up.

Characteristic Pain Pattern
When examining the client, it is not enough to just find pain and dysfunction. It is important to find the specific pain and dysfunction that has brought the client to us. Otherwise, we may be treating other conditions that, although possibly important as well, will not resolve the client’s reason for seeking care in the first place. This can frustrate them and make them feel we are not listening to their concerns. Therefore, it’s important that during the assessment process we find what reproduces their characteristic pain pattern. Once we find the pattern, we will have the correct target for our treatment and can work to resolve the client’s condition.

Unusual Suspect #5
Attachments and Actions
The sternohyoid is an infrahyoid muscle of the anterior neck that attaches from the sternum inferiorly to the hyoid bone superiorly (Image 12). Its concentric action is to depress the hyoid. But it also functions to stabilize the hyoid bone against the pull of the suprahyoid muscles when they act to depress the mandible at the temporomandibular joints; therefore, the sternohyoid engages during temporomandibular joint depression. Because it crosses the cervical spinal joints anteriorly, it can also assist with flexion of the neck at the spinal joints. And because it is located slightly lateral to midline, it can also assist in lateral flexion.

Palpation Assessment
The sternohyoid is superficial, so it is easy to palpate. However, because it is so small, it requires a fine touch to feel and to discern from adjacent musculature. To palpate the sternohyoid, place your palpating fingers between the sternum and hyoid bone and then gently resist the client from depressing the mandible. You will feel the sternohyoid engage (Image 13). Palpate the entirety of the muscle as the client gently contracts and relaxes it. Once located, mild to moderate pressure can be applied to work the muscle.
Note: The anterior neck is a very sensitive region for many clients, so verbal consent should be attained before approaching this area. It is important to check in often with the client regarding the pressure being used.
Because the sternohyoid is located anteriorly and can flex the neck, it is stretched by gently extending the neck. It is also important for the client’s mandible to be elevated (Image 14). The stretch of the sternohyoid on one side can be slightly increased with lateral flexion of the neck to the opposite side.
Note: Extension of the neck should be done very carefully, especially for elderly clients. It is recommended that before stretching the neck, the vertebral artery competency test is first performed (see Vertebral Artery Competency Test, page 60).

Case Study: Sternohyoid
“Mario” was a 30-year-old professional trumpet player who presented with pain in the anterior neck. He reported that approximately one month before, he had been playing trumpet and before he was well warmed up, he attempted to hit a high note and experienced a sharp pain in the front of his neck. Since that day, he had been unable to play without experiencing pain. He had been to several medical doctors, including one who specialized in working with singers and musicians, but no one had been able to diagnose the cause of his pain.
Although he lived nearly two hours away, he came to my office to see if I could help. After examining his neck and assessing all the usual suspects, I palpated his hyoid muscle group, including the sternohyoid. Because the sternohyoid is such a small muscle, assessing its tone is not easy. However, both massaging it and having Mario isometrically contract it by resisting depression of the mandible reproduced his characteristic pain pattern. Armed with the knowledge that he had strained his sternohyoid muscle, I gently massaged and stretched the muscle.
Because Mario lived so far away, he was not able to return for regular care, so I gave him self-care advice that included how to self-massage and stretch the muscle. I also recommended he use a compression bandage that applied gentle pressure to the anterior neck to stabilize the sternohyoid, especially when playing the trumpet. I cautioned him to spend plenty of time warming up before playing and to gradually increase the intensity of his playing over the next month or so. It took approximately 4–6 weeks, but by following the self-care guidelines, Mario was able to make a full recovery and return to playing professionally.

Unusual Suspect #6
Longus Colli and Longus Capitis
Attachments and Actions
The longus colli and capitis are deep muscles of the anterior neck. As a group, they attach to the anterior bodies and transverse processes from T3 all the way to the cranium (Image 15). Because they cross the cervical spinal joints anteriorly, they are flexors of the neck. Because they are located slightly lateral, they can also laterally flex the neck. Besides movement, they also function to stabilize the neck when swallowing.

Palpation Assessment
The longus muscles are deep and located in a sensitive region of the body, but careful palpation can yield successful assessment and treatment of much of the musculature. To palpate them, first find the medial border of the sternocleidomastoid and then drop immediately medial to it. Before attempting to access the longus musculature, first feel for the pulse of the carotid artery. If the pulse is felt to be on either side of your fingertips, then continue the palpation by slowly and gently sinking in posteriorly/posteromedially toward the cervical spine. However, if the artery is felt to be directly in your path, it might be necessary to palpate either medial or lateral to the artery and then sink posteriorly/posteromedially toward the longus musculature.
Most often, palpation is effectively performed medial to the artery. One way to accomplish this is to displace the client’s larynx toward the opposite side of the body, and then sink in posteriorly toward the spine. Because the larynx is a sensitive structure and pressure against it may initiate the cough reflex, this must be done extremely gently. We can tell we have reached the longus musculature by feeling for the hardness of the cervical vertebrae directly deep to the muscle tissue. If we want confirmation that we are on the longus muscles, we can ask the client to engage the musculature by gently lifting their head toward the ceiling (Image 16, page 63). Palpate as much of the longus musculature as possible. Once located, mild to moderate pressure can be applied to work these muscles.

Vertebral Artery Competency Test
The vertebral artery competency test (VACT) should be done before attempting to stretch a client’s neck into extension. Ask the client to gently move her neck into extension, rotation to one side, and lateral flexion to the opposite side, and check for any neural symptoms, such as dizziness, light-headedness, nausea, or ringing in the ears. Also, while performing the test, ask the client to visually focus on any one point and check to see that physical focus on this point can be maintained. The VACT is then repeated for the other side.
A positive VACT indicates lack of arterial blood supply to the back of the brain. If the client is positive to VACT, then it is contraindicated to stretch the neck into extension.
Note: As with the sternohyoid, the anterior neck is a very sensitive region for many clients, so verbal consent should be attained before approaching this area. It is also important to check in often with the client regarding the depth of pressure.

Together, the longus colli and longus capitis flex and laterally flex the head and neck at the spinal joints, so they are stretched by extending and laterally flexing the head and neck to the opposite side (Image 17).  
Note: as with the sternohyoid, stretching the longus musculature by bringing the client’s neck into extension should not be done unless the vertebral artery competency test (VACT) has first been performed (see Vertebral

Artery Competency Test, page 60).
Case Study: Longus Colli and Capitis
“Andrew” was a 45-year-old fast-paced executive who presented with pain in his anterior neck. He said the pain had begun approximately 12 months before and that he didn’t recall any precipitating trauma; the pain began insidiously and had steadily increased over time. Although there did not seem to be a consistent pattern to when the pain was felt, he most often experienced it when swallowing. He said he had been to multiple medical doctors, ruling out nearly every possible pathologic condition of the chest, neck, and throat. Nothing had been found. Needless to say, Andrew was quite concerned about the cause of his pain.
I examined all the joints and musculature of his neck. Although he did have tight musculature in his posterior neck, palpation and engagement of this musculature did not reproduce his characteristic pain pattern. However, when I palpated anteriorly into his longus musculature, he immediately felt the pain he had been experiencing for the past year or so. He had tight longus musculature.
When I explained to Andrew what the cause of his pain was, he was greatly relieved to learn his condition was not life-threatening in any way. Because of his work demands, and knowing that the condition was not dangerous, he declined to come in for a regimen of treatment because of the time it would take away from his work. In lieu of treatment, I advised him to gently massage and stretch the area. I never saw Andrew again, but his wife, who was a regular client of mine, told me his pain had gradually dissipated over the course of a few months.

A dedication to further exploring and learning
The goal of clinical orthopedic manual therapy is to resolve the musculoskeletal condition with which our client presents. However, this is not possible if we do not know which muscle or muscle group is involved. To determine this, an accurate and thorough assessment is needed; and this requires knowledge and awareness of not only the usual suspects but also the unusual suspects. Toward this end, the goal of this feature has been to whet our appetites by presenting a number of unusual suspect muscles for consideration, but many more exist. It is only with a dedication to exploring and learning all the musculature of the body that we can assure ourselves of having a lasting and successful clinical orthopedic manual therapy practice.

Other Unusual Suspects
This feature presented and went into some depth discussing six unusual suspect muscles, each one of which may be the underlying cause of client conditions. However, there are many more unusual suspects that could have been presented. Following is a brief discussion of a few more unusual suspects.

The pectineus is a transitional muscle between the hip flexor and hip adductor compartments. It is located between the psoas major of the flexor compartment and adductor longus of the adductor compartment (Image B). It is often missed because the therapist’s focus is so often on the psoas major. And because the pectineus sits a bit deeper than its neighbors, it is more challenging to find. The easiest way to locate the pectineus is to first find the proximal tendon of the adductor longus, and then drop immediately lateral to it. Keep pressure close to the pubic bone and ask the client to try to move the thigh at the hip joint, against your resistance, in an oblique plane that is a combination of flexion and adduction.

Vastus Lateralis
The vastus lateralis is a member of the quadriceps femoris group. As such, it is often thought of as being located only in the anterior thigh. However, the vastus lateralis attaches to the lateral lip of the linea aspera of the femur located all the way on the posterior side of the bone (Image C). Therefore, even though the vastus lateralis is superficial anterolaterally, it is also located in the lateral and posterolateral thigh. It is the lateral thigh where it is often overlooked as the causative agent of the client’s pain. Because the iliotibial band is located superficial to the vastus lateralis, the iliotibial band is often blamed as the cause of the pain when the deeper vastus lateralis is the true culprit.
When the iliotibial band is the cause of the client’s condition, the pain will usually be felt at the lateral femoral condyle. If the client’s pain is anywhere mid-thigh, look instead to locate and assess the vastus lateralis. This is easy. To locate it, simply resist the client from trying to extend the leg at the knee joint and feel for the vastus lateralis to engage. Once the muscle is located, have the client relax it and assess its tone.

Semispinalis Capitis
The semispinalis capitis of the posterior cervical spine is often overlooked as the cause of pain and tightness in the neck (Image A). It is actually the thickest muscle in the back of the neck and often tight and symptomatic. It lies directly deep to the upper trapezius, so the upper trapezius is often blamed when the semispinalis is the offending culprit. When assessing clients with neck tightness and pain, look for the semispinalis. Deep work over the laminar groove, directly lateral to the spinous processes, is often the key to helping clients with a tight semispinalis capitis.

Joseph E. Muscolino, DC, has been a manual and movement therapy educator for more than 30 years. He is the author of multiple textbooks, including The Muscular System Manual: The Skeletal Muscles of the Human Body (Elsevier, 2017); The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns, and Stretching (Elsevier, 2016); and Kinesiology: The Skeletal System and Muscle Function (Elsevier, 2017). He is also the author of 12 DVDs on manual and movement therapy and teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy (COMT). He has created Digital COMT,
a video streaming subscription service. Visit for more information or reach him directly at