Suboccipitals: Small But Important!

The suboccipital muscles are four small muscles attaching at either the C1 (atlas) or C2 (axis) vertebrae – from either the spinous or transverse processes.  All but one of these muscle, obliquus capitis inferior, go on to attach to the base of the occiput.

As a group, the suboccipital muscles function to rock and tilt the head into extension.  The rectus capitis posterior major and obliquus capitis inferior assist in rotation of the head to the ipsilateral (same) side.  Additionally, these muscles play a critical role in stabilization and fine movement control of the cranium on the atlas, and the atlas on the axis.

Rectus Capitis Posterior Minor: A Minor Muscle With Major Implications

Of the suboccipital musles, Rectus capitis posterior minor is particularly interesting. 

Rectus capitis posterior minor has been shown to have a high density of muscle spindles, which may indicate its role in movement is not as important as its role in proprioception of both the head and cervical spine.  For this reason, atrophy of the rectus capitis posterior minor that may occur following injury or trauma can lead to diminished proprioception and balance.  A study conducted by McPartland et al. showed that subjects with chronic neck pain and rectus capitis posterior minor atrophy displayed a decrease in standing balance when compared with a control group.  Interestingly, a study conducted by Moseley assessed voluntary trunk muscle activation (draw-in maneuver) as a way to pick out those with neck pain verse the control subjects.  Additionally, those who had neck pain were 3 to 6 times likely to develop low-back pain.  Perhaps the poor trunk muscle activation (inner core) in the neck pain patients was the reason that those with chronic neck pain in McPartland’s study also displayed a lack of balance?

Further, rectus capitis posterior minor has been noted to have a fascial bridge into our dura mater (the outer layer of the meninges which surrounds our spinal cord and brain).  A potential role that rectus capitis posterior minor plays is to try and regulate dural folding, or movement of dura towards the spinal cord – which occurs during head extension.  It has been inferred that individuals may experience headaches and pain when the rectus capitis posterior minor muscle acts inappropriately on dura.

Upper Crossed Syndrome & Forward Head Posture

Upper crossed syndrome is a postural distortion pattern noted by Dr. Vladimir Janda.  What we see in this pattern is an individual who displays a large amount of kyphosis in their upper back (thoracic spine), a forward head (poking chin) and rounded or slumped shoulders.  As we can see in the picture above, the individual with upper crossed syndrome will present with weakened deep neck flexors (longus coli and capitis), rhomboids and serratus anterior; and tight pectoral muscles (pectoralis major and minor), upper trapezius and levator scapula. 

This posture has become relatively common in today’s society:

One of the roles of the suboccipital musculature is to afford us the ability to see straight ahead.  In an upper crossed pattern, the only way this would be possible is for us to contract the suboccipitals, effectively extending the head and neck, so that our eyes can remain looking at the horizon.  Along with this, Janda has discussed the role of the oculopelvic and pelviocular reflexes, which show that a change in pelvic position will alter the position of the eyes and vice versa.  Eye movements play a role in muscle tone, especially for the suboccipitals, as looking upwards will increase tension in the extensor muscles (which the suboccipitals belong to) and looking down will increase tension in the flexors (and decrease tension in the extensors).

Chronic shortening of the suboccipitals that is observed in a forward head posture may lead to ischemia and trigger points.  As you can see from the picture below, trigger points in this region will refer a “headache like” pain pattern:

Appropriate soft tissue therapy, stretching and exercise can help to alleviate tension in the suboccipital muscles, and decrease trigger points which may be referring their common pattern.  Additionally, stress is often accompanied by tightness in the head and neck.  Relaxation techniques such as diaphragmatic breathing or massage therapy may help to decrease stress and subsequently decrease tension in the muscles of the posterior neck.

Suboccipitals and Hamstring Tightness?

Up to this point, we have focused on the suboccipital muscles locally.  Looking more globally, we can further discuss the utilization of suboccipital stretching to help inhibit hamstring tightness and improve hip flexion range of motion.

Aparicio et al. used a method called Suboccipital Muscle Inhibition Technique to evaluate the effect that “releasing” the subbocipital muscles would have on hamstring muscle elasticity.  This technique consisted of the therapist placing an upward pressure on the posterior arch of the atlas (C1) of the supine patient for approximately 2 minutes, until tissue relaxation had been achieved.  Following this technique, the subjects in the suboccipital muscle inhibition technique group saw greater improvements in finger-floor distance test, straight leg raise, and popliteal angle test compared to the control group (who received a placebo manual therapy technique).

There are several hypotheses for the positive result of this treatment:

1. The connection to dura mater – This plays to the continuity of the nervous system and how it links everything together.
2. Postural control - The suboccipitals play a role in postural control and will affect the coordinated movement of muscles down the chain.
3. Myofascial chains - Both the suboccipitals and the hamstring musculature are included in the superficial back line.  Addressing any of the structures in the superficial back line may have a positive effect of the entire line itself. 

In addition to the above technique, Chaitow and DeLany discuss using muscle energy techniques (contract-relax stretching) for the suboccipital muscles to help improve hamstring length. 

Finally, the therapist can include the use of eye movements while performing the muscle energy technique protocol for the suboccipitals.  Having the client look upward during the contraction of the suboccipitals will further increase contraction of the extensors of the body, increasing fatigue of those muscles once the contraction has ended.  Following the contract phase, the client will then relax and the therapist can stretch the suboccipitals and have the client look down with their eyes (towards their chin) to inhibit the extensors, including the hamstrings, via reciprocal inhibition as the flexors are “turned on”.

These techniques will come in handy in a couple of situations:

1. In dealing with clients with extremely tight hamstrings, that attempting to stretch them is painful, or not possible.
2. During times of injury, when it would not be advised to passively take the hamstrings through a stretch.

Soft Tissue Ideas of Suboccipital Treatment

There are several treatment options for the suboccipital muscles and the major players, are always a safe bet:

• Compression
• Friction (be aware of your hand position for this!)
• Positional Release
• Muscle Energy Techniques (as discussed above)

Trying to get the patient to relax and get comfortable is paramount over everything else when doing neck work (or any work for that matter!).  This is not an area that we should be aggressive in, and appropriate touch and palpation is critical to a safe and effective treatment. 

One area that we need to be particularly cautious of is the suboccipital triangle:

As you can see, the borders of obliquus capitis inferior, opliquus capitis superior and rectus capitis posterior minor form this triangle.  Not pictured in this photo is the vertebral artery, which runs through the center of the triangle and is relatively exposed.  Aggressively poking into this area or frictioning over it could potentially damage the artery.  In a nutshell, “It’s better to be safe than sorry”.

Compression & Friction

Applying compression or friction to these muscles can be done so at the base of the occiput and even on the posterior tubercle of C1 and the spinous process of C2.  Staying near the spinous process will ensure that you are not in the suboccipital triangle and you are away from the vertebral artery.  Obviously if you feel a pulse under your fingers, change the position of your palpation.  Take your time to slowly investigate these structures for trigger points and ischemia.  Additionally, it helps to remember that the suboccipital muscles lie deep to other muscles, so don’t be in a hurry to slam through all the superficial tissue.  Take your time to appropriately assess the tissue for tone and tension, and ensure that the techniques are not producing pain and the client is comfortable enough for you to work deeper.  When you find trigger points that are referring their common pattern (up into the head and behind the eyes) just hold that point for 8-12sec until the referral dissipates, and then move on to investigate the tissue next to it, keeping in mind that trigger points often form in clusters.

Sometimes, all that the client may need – or be able to tolerate – is gentle compression at the cranial base (and sometimes some light traction), as this generally gets people to relax, and when the tissue tension has been brought on by stress, this is a most welcomed technique.

Muscle Energy & Positional Release Techniques

Muscle energy and positional release techniques are two excellent choices for treatment of tissues that are hypertonic or tense.

Muscle energy techniques were discussed above with regard to hamstring release, however it is important to remind the therapist that the goal is to try and get all of your movement (contraction and then the passive movement to the next barrier of resistance) from the Atlas (C1) and Axis (C2).  A good way to do this is to place one hand behind the head of the supine client, and then other hand on top of their forehead.  This will help you move the head into flexion, stretching the suboccipitals, without getting too much contribution from the lower spine (C3-7).  Additionally, in some acute situations, where there is pain upon isometric contraction (extension) of the suboccipitals, you can try and have the client contract the deep neck flexors (nodding their chin towards their adam’s apple and placing an isometric contraction into your hand which is on their forehead) to try and allow the suboccipitals to relax via reciprocal inhibition before taking them to their next stretch barrier.

Finally, positional release techniques are a great non-painful way to address areas of tenderness.  For the suboccipitals, with the client lying supine, palpate to find a tender point.  The client confirms the point as being tender and is asked to rate the point as a tenderness score of “10”.  Maintaining pressure on that tender point the head is then eased back into slight extension until the client reports that tenderness has decreased.  From this position, with the current tenderness decreased from its previous score of “10”, the head is gently moved into rotation and side bending, to help “fine-tune” the position of release, and decrease the clients tenderness score even further.  For fine-tuning, you will need to play with this, as each client will have a different position that they favor.  Some like ipsilateral rotation and/or side bending, while others prefer contralateral rotation and/or side bending.  The client is in charge here, and whichever position decreases their tenderness score, that is the position you will go with.  Once the tenderness score has decreased by 70% (so down to a 3 out of 10), the client is then just asked to relax and monitor their breathing, as the point is held for approximately 90 seconds.  The head is then returned back to the test position and the tender point is re-palpated to see if tenderness has decreased.

A Word On Breathing During These Techniques

As with all of these techniques, breathing is very important, and developing healthy breathing habits are critical for decreasing upper neck tension.  Additionally, proper breathing will help lead to greater relaxation and a decrease in overall muscle tone.

Exercise

Integrating the individual back into function should be the overall goal, and taking care to teach appropriate neck position during exercise is an important part of the puzzle.  Care should be taken to ensure that during exercises, the client is not using the upper neck musculature to provide stability, a “high threshold strategy”, and the suboccipitals should not be allowing the head to go into hyperextension.  A good way to ensure that the neck musculature is in the appropriate position is to have the client perform a chin tuck during their exercises (pulling their chin towards their adam’s apple), as this will place the posterior neck muscles on stretch, and turn on the often weak deep neck flexors (longus coli and capitis).

Conclusions

The suboccipital muscles play an important role in movement of the head, posture, and function of the entire body.  Taking care to assess and treat these muscles with the appropriate soft tissue techniques and re-integrating them back into proper exercise and function is essential for well-being of your clients, patients or athletes.

References

Neumann DA. Kinesiology of the Musculoskeletal System. Mosby. 2002.

Kendall FP, McCreary Ek, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function with Posture and Pain. Lippincott, Williams and Wilkins. 5th ed. 2005.

Chaitow L, DeLany J. Clinical Application of Neuromuscular Techniques Vol 1: The Upper Body. Churchill Livingstone. 2000.

Chaitow L, DeLany J. Clinical Application of Neuromuscular Techniques Vol 2: The Lower Body. Churchill Livingstone. 2000.

McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain, standing balance, and suboccipical muscle atropy – a pilot study. J Manipulative Physiol Ther 1997; 20(1): 24-9.

Moseley GL. Impaired trunk muscle function in patients with sub-acute neck pain: etiologic in the subsequent development of low-back pain. Manual Thearpy 2004;9:157-163.

Aparicio EQ, Quirante LB, Blanco CR, Sendin FA. Immediate effects of the suboccipital muscle inhibition technique in subjects with short hamstring syndrome. J Manipulative Physiol Ther 2009;32(4):262-269.

McPartland JM, Brodeur RR. Rectus Capitis Posterior Minor: A Small But Important Suboccipital Muscle. Journal of Body Work and Movement Therapy 1999: 3(1), 30-35.