Muscle:Cervical Rotatores

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Cervical rotatores are the shortest and deepest paraspinal muscles of the posterior cervical spine. Their trigger points (TrPs) produce midline pain and tenderness at the segmental level of the TrP — a pattern analogous to that described for thoracolumbar rotatores. Unlike the longer posterior cervical muscles, their taut bands cannot be identified by palpation; they must be identified by characteristic deep tenderness to pressure in the groove lateral to spinous processes, and by tenderness to pressure or tapping on the spinous process of the vertebra to which the muscle attaches.

TrPs in the cervical rotatores are closely and directly associated with articular dysfunction at the same segmental level. The articular dysfunctions commonly associated with them are often corrected by suboccipital decompression, or other manipulative medicine techniques.

Contents

Anatomy

The cervical rotatores, when present, begin at C₂ and continue downward segmentally. They are the shortest and deepest paraspinal muscles, connecting to adjacent or alternate vertebrae. They constitute the fourth and deepest layer of the posterior cervical muscles (with the cervical multifidi), lying directly over the laminae of the vertebrae. They are therefore the muscular layer immediately superficial to needle contact with the lamina during injection.

The degree of angulation of these muscles has important functional implications: the rotatores are the most angulated of all the posterior cervical muscles and therefore the most effective of these muscles for spinal rotation.

The cervical rotatores are often not as fully developed in the cervical region as they are in the thoracic region. Their taut bands cannot be identified by the direction of their fibres on palpation — they must be identified by deep pressure tenderness.

Primary actions: Rotation of the vertebrae to the opposite side (most effective paraspinal rotators due to maximum fibre angulation); extension of the vertebral column when acting bilaterally.

Innervation: Branches of the posterior primary divisions of the cervical spinal nerves.

Synergists (extension and rotation): Semispinalis cervicis; for each separate movement, additional synergists and antagonists are the same as those for the semispinalis cervicis.

Referred Pain Patterns

When present, TrPs of the cervical rotatores produce midline pain and tenderness at the segmental level of the TrP, analogous to that described for thoracolumbar rotatores under Deep Paraspinal Muscles in Chapter 48. Pain is elicited by application of pressure or tapping on the spinous process(es) of the vertebra(e) to which the muscle attaches.

This tenderness testing is used also to identify dysfunctional spinal articulations.

The pain arising from the cervical multifidi (with which the rotatores are functionally grouped) is analogous to the pattern of pain arising from the corresponding deep layer of muscles in the lumbar spine: both refer pain locally adjacent to the spinous process and may refer additional patterns several segments away from the TrP.

Activation and Perpetuating Factors

  • Articular dysfunction: The most direct activating factor for cervical rotatores TrPs is articular dysfunction at the same segmental level; the two conditions are closely associated and frequently coexist
  • Motor vehicle accident (whiplash): the semispinalis cervicis, multifidi, and rotatores muscle groups can form articular dysfunctions at various levels of the cervical and upper thoracic spine depending on specific attachments
  • Sustained forward head posture with the neck in flexion
  • Neuropathy: increased nerve irritability from spinal radiculopathy or segmental dysfunction
  • Extension dysfunctions of T₁–T₄: the bilateral posterior cervical muscles that attach to or span the upper thoracic vertebrae — particularly the semispinalis cervicis, multifidi, and rotatores with attachments in the upper thoracic region, as well as the semispinalis thoracis digitations that extend to and cross the upper thoracic vertebral segments — are particularly difficult to isolate; extension dysfunctions of T₁–T₄ are an important articular dysfunction associated with TrP involvement of these muscles

Clinical Examination

The cervical rotatores lie too deep for the fibre direction of their taut bands to be identified by palpation. They must be identified by:

  1. Deep tenderness to pressure applied deep in the groove lateral to the spinous processes
  2. Tenderness to applied pressure or tapping on the spinous process of the vertebra to which the muscle attaches — this spinous process tenderness testing is used also to identify dysfunctional spinal articulations

Distinguishing rotatores from multifidi on examination:

  • Multiple bilateral deep short rotatores can look like the longer but less angulated multifidi on palpation
  • Rotatores involvement causes more restricted rotation than multifidi involvement
  • Multifidi are less likely to cause a contiguous series of pressure-sensitive vertebrae with restricted joint mobility
  • Multifidi involvement would not cause as much restricted rotation as the rotatores do

Articular assessment: The close relationship between rotatores TrPs and articular dysfunction means that a careful evaluation of cervical joint function at corresponding segmental levels is essential. Restriction in all directions usually indicates a capsular (arthritic) pattern rather than a dysfunctional (myofascial) one.

A flattened spot in the normally smooth curvature of the thoracic region, identified when tested by forward flexion (at least one spinous process fails to stand out prominently as expected), indicates the segmental level of TrP involvement in the deep paraspinal muscles.

Differential Diagnosis

Condition Distinguishing features
Cervical zygapophysial joint pain Tenderness to spinous process pressure is shared by both rotatores TrPs and articular dysfunction; the two conditions coexist so frequently that both must be assessed at each segmental level; myofascial TrP pain responds to TrP pressure release and injection; articular dysfunction responds to manipulation
Cervical multifidi TrPs Multifidi are longer, less angulated, and less effective at rotation; rotatores TrPs produce more restricted rotation; multifidi TrPs are less likely to produce contiguous vertebral pressure sensitivity; palpation depth and fibre angulation differ
Cervical radiculopathy Positive Spurling test; dermatomal limb signs; electrodiagnostic findings; TrPs and radiculopathy coexist — each diagnosed on its own criteria; posterior cervical TrPs alone do not produce limb symptoms
Counterstrain tender points (Jones) Jones mapped tender tissue texture changes near bony attachments of tendons, ligaments, or muscle bellies in the upper posterior cervical region — at the C₁ transverse processes, along the mandibular rami — associated with impaired or altered function of the upper cervical segment; clinicians using both systems comment on significant overlap

Treatment

Trigger Point Release

Treatment of full-range stretching is contraindicated across joints that exhibit primary hypermobility. When TrPs cross hypermobile joints, use TrP pressure release, hold-relax (mild contraction only), counterstrain, indirect myofascial release, or TrP injection.

Released as part of the diagonal posterior cervical muscle group, using the same technique as for the semispinalis cervicis (flexion-with-rotation spray and stretch, Fig. 16.7). See Semispinalis Cervicis — Trigger Point Release for the full diagonal stretch technique.

The articular dysfunctions commonly associated with TrPs in the deep diagonal semispinalis cervicis, multifidi, and rotatores muscles are often corrected by suboccipital decompression, or other manipulative medicine techniques.

Restriction may respond well to appropriate bilateral stretch and spray of the deep paraspinal muscles that span the level of the flattening, or to manual techniques designed to affect both joint and muscle function. Treat extension dysfunctions from T₁ to T₄ using a manual stretch technique that incorporates contract-relax and forward flexion progressing down the spine segment by segment.

One must avoid injection at the point of neural entrapment (where the greater occipital nerve passes through the semispinalis capitis); however, injection of the TrP in the muscle that is contributing to the entrapment is appropriate therapy.

Trigger Point Injection

TrPs in the rotatores are reached by penetrating several layers of muscle — after passing through the trapezius, splenius capitis, semispinalis capitis, and semispinalis cervicis. The TrP is usually encountered at least 2 cm (¾ in) deep to the skin, and may lie beyond the reach of a 3.8-cm (1½-in) needle — a 5-cm (2-in) needle is often needed (Fig. 16.8 of the source volume).

The rotatores lie directly over the laminae of the vertebrae, so they are the muscular layer immediately superficial to needle contact with the lamina. It helps to depress the skin on both sides of the needle while injecting.

Vertebral artery avoidance: avoid injections deep into the lateral posterior neck at, or above, the level of the C₂ spinous process (Fig. 16.5).

Following injection: passive rotation stretch during vapocooling, then active full rotations (two or three times each direction), then moist heat.

Corrective Actions

Same as for Semispinalis Capitis — Corrective Actions.

Patients who exhibit primary hypermobility require stabilising exercises rather than stretching exercises. The patient can use TrP pressure release, self-massage, self-positioned counterstrain, and the hold-relax technique to inactivate or prevent reactivation of the TrP.

Satellite Trigger Points

References

  • Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1: The Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 16.
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