Key Points

• The suboccipital muscles play a unique role in
head-righting reflexes because of their high density of muscle spindles.

• Releasing tension in tight suboccipitals and creating the opportunity for proper atlas and axis alignment becomes an important goal when clients report head and neck pain. 

Among the intricate tapestry of bones, muscles, tendons, ligaments, and fascia exist eight structures that have long captivated the attention of massage therapists and bodyworkers. At the juncture where the spine meets the skull, the suboccipital muscles play a pivotal role in our daily lives. Along with the inner ear’s vestibular system, they help keep our gaze level with the horizon while facilitating the fine-tuned movements that allow us to nod “yes” to life—or look at the stars.  

The suboccipitals are a testament to the sophisticated design of our anatomy and the delicate interplay between structure and function. Their location, intimately close to vital neurological pathways, means that disturbances here can reverberate throughout the body. Therefore, part of the fascination of the suboccipitals lies in the stories they tell our hands about a client’s life. When we touch these muscles, we glean insights into how this person sits at their desk, cradles their phone, or stands in conversation with a group of friends. The suboccipitals help us understand the burdens a person carries, both physically and metaphorically. 

Let’s delve deeper into the mystique of the suboccipitals to better understand these small muscles and their huge importance to a life free of head pain.

Suboccipital Anatomy and Physiology

Most massage therapists know that the suboccipital muscles reside at the base of the skull, where they orchestrate delicate movements of the head and help stabilize the atlanto-occipital (OA) and atlantoaxial (AA) joints (Image 1). These paired muscles are the rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis superior, and obliquus capitis inferior.  

Rectus capitis posterior major originates from the spinous process of the axis and inserts into the lateral part of the inferior nuchal line of the occipital bone. It assists in extending the head at the OA joint and ipsilateral head rotation. 

Rectus capitis posterior minor originates from the posterior tubercle of the atlas and inserts into the medial part of the inferior nuchal line of the occipital bone and the neighboring part of the occipital bone below this line. It helps in extending the head at the OA joint and assists in ipsilateral rotation of the head. 

Obliquus capitis superior originates from the transverse process of the atlas and inserts into the lateral portion of the inferior nuchal line of the occipital bone. Obliquus capitis superior assists in extending the head at the OA joint and lateral head flexion. 

Obliquus capitis inferior originates from the spinous process of the axis and passes laterally, slanting upward to insert on the transverse process of the atlas. It is the most laterally placed among the suboccipital muscles and the only “capitis” muscle that does not attach to the skull. The obliquus capitis inferior muscles function in rotation at the AA joint.

In an optimal head and neck position, the ear (external auditory meatus) generally aligns vertically over the shoulder’s acromion, and the cervical spine assumes a natural lordotic curve that properly distributes the head’s weight across the cervical vertebrae. Unfortunately, modern lifestyles of people hunched over computers or smartphones promote forward-head postures (Image 2). 

A forward-head posture causes an anterior shift of the head out of neutral alignment. The lower cervical vertebrae flex forward, causing the upper cervical segments to hyperextend. This posture has several negative consequences, including stress on facet joints and intervertebral discs, a compressed chest cavity and reduced lung capacity, neural impingement, and the altered position of the shoulder girdle. 

The suboccipital muscles experience excessive strain. As the head moves forward relative to the spine, the chin juts out. The head feels heavier to the structures responsible for supporting it because the head’s center of gravity has shifted (Image 3). Now, the posterior neck muscles must work harder to keep the eyes level. Sustained isometric contraction in the suboccipital muscles causes joint compression and, over time, may cause damage to the articular cartilage of the OA condyles. We’ll find that a forward-head posture is a primary contributor to the suboccipital-related conditions we discuss here. 

The Suboccipitals and Dizziness

Spin on a dance floor or step onto the tilting deck of a sailboat and imagine what would happen to your body if head-righting reflexes didn’t help you maintain your equilibrium. When the head moves or changes its orientation relative to gravity, the suboccipitals and the vestibular system of the inner ear work in tandem to provide accurate feedback to the brain. Head-righting reflexes are crucial for maintaining the head’s orientation in space and keeping the eyes on a horizontal plane irrespective of the body’s position. A level head and stable visual field are essential for accurately judging distances and throwing objects or engaging in the complex motor movements used to participate in daily activities. 

The suboccipital muscles play a unique role in head-righting reflexes because of their high density of muscle spindles. Massage therapists will remember these sensory receptors located within muscle fibers are sensitive to changes in muscle length and velocity (the rate at which muscle length changes). They are integral to balance, coordination, and the body’s innate sense of self in space. The dense concentration of muscle spindles in the suboccipitals (compared to other muscles of similar size) suggests a highly specialized role in proprioception and the fine-tuning of head movements. 

Researchers found that chronic forward-head posture results in functional and structural changes in the suboccipital muscles. Except for obliquus capitis inferior, which acts in head rotation, the suboccipitals undergo the most significant shortening of the occipital extensors. These changes in length influence the binding action between actin and myosin filaments, reducing the ability of these muscles to generate force (strength) and resist fatigue (endurance). Over time, the rectus capitis posterior major and minor muscles atrophy, causing adipose cells to accumulate within the muscle tissue (myosteatosis). When adipose replaces muscle tissue, it reduces the density of muscle spindles, resulting in inaccurate positional signaling to the brain. 

Altered proprioception in the suboccipitals disrupts the normal function of head-righting reflexes, causing dizziness and issues with balance and coordination. When the brain gets confusing signals about the head and body position, it may splint the cervical spine with protective muscle spasms, contributing to neck pain and headache. 

The Suboccipitals and Cervicogenic Headaches

Cervicogenic headache is a general term for head pain originating from cervical spine disorders. Cervicogenic pain often relates to hypertension or spasms in the muscles that create the suboccipital triangles. 

The suboccipital triangles are formed on either side of the upper cervical spine by the arrangement of three suboccipital muscles (Image 4). The obliquus capitis superior muscles form the superior borders of each triangle. The obliquus capitis inferior muscles form the inferior borders, and the rectus capitis posterior major forms the medial borders. The suboccipital triangles act as a space for the passage of the vertebral arteries and the suboccipital nerves. The suboccipital nerves are motor nerves that don’t produce pain sensations. However, several nerves that exit the upper cervical complex travel near the suboccipital triangles, where tight or spasming suboccipital muscles might compress them, causing headache pain. 

For example, occipital neuralgia is a neuropathic pain syndrome characterized by sudden and severe stabbing pain in the distribution area of the occipital nerves. The etiology of occipital neuralgia is multifactorial and may include inflammation of the occipital nerves because of rheumatoid arthritis, diabetes, direct trauma, or other causes. However, compression of the nerves by tight muscles in the neck is often a factor (Image 5). Consider that the greater occipital nerve originates from the C2 spinal nerve root. It emerges between the atlas and axis and ascends upward. As it travels, it pierces the semispinalis capitis muscle and then crosses the suboccipital triangle near its apex. After passing the triangle, the nerve continues upward to innervate the scalp up to the vertex of the skull. Tight or spasming suboccipital muscles can compress the nerve, causing pain. 

Hypertonicity or spasm in the muscles of the suboccipital triangle may also lead to minor compression of the vertebral artery, reducing blood flow to the brain and resulting in lightheadedness and dizziness. 

Another type of cervicogenic condition is stomach sleeper’s headache. It occurs because stomach sleepers typically turn their head to one side to breathe. As we’ve discussed, the obliquus capitis inferior muscles arise from the spinous processes of the axis and insert on the transverse processes of the atlas. The primary function of the obliquus capitis inferior muscles is head-on-neck rotation. With stomach sleeping, one obliquus capitis inferior muscle remains shortened while the other remains lengthened for a prolonged period.

Ideally, the atlas vertebra rotates with the head, but with a shortened obliquus capitis inferior, the atlas drags the axis with it. So, when the stomach-sleeping client rises from bed and attempts to rotate their head to neutral, the affected obliquus capitis inferior muscle spasms, fixing the atlas on the axis. If a person forces their head to rotate, the joint jamming moves down the chain to C3, causing the brain to splint the area with protective muscle guarding and amplifying pain. 

The Suboccipitals and Dural Torsion 

The dura mater (dura) is the outermost, thickest, and toughest layer of the meninges. Massage therapists will remember that the meninges are three layers of membrane that cover and protect the brain and spinal cord and separate them from their bony cases, the skull and vertebral column (Image 6). 

Superiorly, the spinal dura attaches to the circumference of the foramen magnum and the posterior longitudinal ligament. The foramen magnum is the large, oval-shaped opening in the skull’s occipital bone. The spinal cord passes through the foramen magnum as it exits the cranial cavity. The posterior longitudinal ligament connects and stabilizes the bones of the spinal column. It runs adjacent to the spinal cord almost the entire length of the spine from the axis to the sacrum. 

Inferiorly, the spinal dura extends below the spinal cord termination to end at S2, becoming a thin cord known as the coccygeal ligament anchoring the dural sac to the sacral periosteum. 

Several anatomical asymmetries can place excessive tension on the dura, including scoliosis, hyperkyphosis, hyperlordosis, or a sacrum that’s rotated, tilted, shifted anteriorly, or shifted posteriorly. As you’ve probably guessed, alterations in the alignment and kinematics of the OA and AA joints and the muscles that cross them can overstretch and torque the dura. 

For example, a forward-head posture causes notable hypertonicities in the rectus capitis posterior major and minor. Interestingly, these muscles form a myodural bridge or specific soft-tissue connection to the posterior atlanto-occipital membrane and the dura mater. As a result, tension in the rectus capitis posterior major and minor translates directly to drag on the dura. Consider how asymmetries at both the top and bottom of the spinal column create multiple points of tension, torque, or drag that amplify an overstretch on the dura. Several things can happen: 

• An overstretch of the dura can alter the intensity and frequency of nerve signals to and from the brain.
• When the dura is under stress, some of its cells release chemicals that heighten pain perception and increase tissue inflammation. 
• Overstretched dura may compress branches of the trigeminal and upper cervical nerves, leading to referred pain in areas these nerves supply.
• The dura plays a role in the containment of cerebrospinal fluid (CSF), so compression can interfere with CSF dynamics. 

Releasing tension in tight suboccipitals and creating the opportunity for proper atlas and axis alignment becomes an important goal when clients report head and neck pain.  

A Holistic Approach to Suboccipital Dysfunction 

Most massage therapists know that those with a forward-head posture may be suffering from a common muscle imbalance problem called upper crossed syndrome (UCS). In the late 1980s, famed neurologist and researcher Vladimir Janda, MD, and his team at Charles University in Prague, found that when stressed, some muscles tighten and become neurologically facilitated (tight), while others become weak and inhibited. They also found that these muscle imbalances formed a predictable forward-head carriage. 

In an upper cross pattern, the upper trapezius and levator scapula are tight and the neck flexors (anterior scalene, longus capitis, longus colli) are inhibited. Tight pectorals are accompanied by inhibited rhomboids and serratus anterior muscles. Along with a hypertonic upper trapezius and levator scapula, a client with a forward-head posture and contracted suboccipitals is likely to exhibit a hypertonic splenius capitis, semispinalis capitis, and splenius cervicis. 

Our session outcomes won’t be effective if we work exhaustively on the suboccipitals, ignoring the other muscles involved in an upper cross pattern. For this reason, myoskeletal alignment technique (MAT) takes a holistic approach to the cervical region. 

One of the systems MAT employs is the use of thoughtfully crafted routines. In manual therapy, a routine is a series of carefully chosen techniques delivered to body regions in a specific sequence to achieve defined outcomes. MAT routines take the guesswork out of treating many conditions because they integrate massage with movement strategies like graded exposure stretching, nerve gliding, and nerve tensioning, creating a comprehensive and inclusive treatment protocol. 

The repeated application of a particular routine often corrects the core biomechanical issues at play in a particular musculoskeletal pathology, resulting in significant improvements for clients with moderate to severe symptoms. When a client requires additional specialized methods, MAT uses orthopedic assessment to help therapists choose targeted techniques.  

I’ll share eight techniques from the much longer MAT cervical routine for this article. Incorporate these methods into your neck massage to bring greater focus to the OA and AA joints and the suboccipital muscles. Use these techniques to prevent dysfunction in healthy necks and as a treatment for clients who exhibit upper cross syndrome or forward-head postures. 

8 MAT Techniques for the Cervical Region

Opening Neck Stretch

This technique softens the posterior and lateral cervical soft tissue. First, stand on the client’s right with your left hand on the client’s forehead and your right hand draped over and around the client’s lateral neck. Establish a counterforce as your right hand (and extended arm) gently pulls the soft tissue of the client’s neck anteriorly. At the same time, your left hand resists the client’s right head rotation. As you continue this rhythmic maneuver, curl your fingers to hook the suboccipitals and pull them anteriorly to work across their fibers. Repeat this stretch on the opposite side. 

Trap Hook

This technique helps release a hypertonic upper trapezius. Cradle the client’s head with your right hand and gently move it into right side bending and rotation. Use your left hand in a soft fist to hook the upper traps and drag the tissue laterally as you continue to move the client’s head into right side bending and rotation. Make two to three passes and then repeat this technique on the opposite side.  

Cervical Decompression 

This maneuver tractions the client’s neck to decompress the cervical joints. Lift the client’s head to slide your right forearm under the client’s neck with your palm up. Use your left hand to brace the client’s forehead. Pronate your forearm using your radius to hook the tissue while continuing to brace the client’s forehead. Return your arm to the starting position by supinating your forearm and repeat this movement for two minutes. Move to the client’s left side and repeat the technique for an additional two minutes. 

OA Chin Tuck 

This procedure mobilizes the OA joint and stretches the suboccipitals. Standing at the head of the therapy table, slide your right hand under the client’s head to cradle their head. Use your left hand to brace the client’s forehead. Ask the client to tuck their chin to their chest. With your elbows extended and your hands fixed, step to your left foot and apply a gentle two-second overpressure that places a stretch on the suboccipitals and encourages the occipital condyles to glide posteriorly. Work within the client’s comfort zone and repeat the chin tuck three or four times. Reverse your hand position, step onto your right foot, and repeat the technique three or four times.  

Atlas-Axis Technique 

This technique stretches the obliquus capitis inferior and frees the AA joint. With your left hand, lift the client’s head to flex their neck to 45 degrees and stabilize their head in this position with your right hand on their forehead. Visualize a pole running straight through the client’s head and neck. Maintain this 45-degree position throughout this technique because it ligamentously locks C2 through C7 and allows you to isolate atlas-axis rotation. 

Slowly rotate the client’s head to the right and back to the left. If the client’s movement is restricted in right rotation, turn their head until you meet their first restrictive barrier, then back off slightly. Ask the client to turn their head gently to left rotation against your resistance to a count of five and then relax. Take their head back into right rotation to the next restrictive barrier, back off slightly, and repeat this process up to five times. If the client’s movement is restricted in left rotation, turn their head to the left and repeat the appropriate steps above from that position. 

Suboccipital Release No. 1

This rhythmic, soothing technique releases the suboccipital muscles. With your curled finger pads, grasp the lateral suboccipital muscles on both sides of the client’s neck. As you step onto your left foot, your fingers pull superiorly on the suboccipitals on the left. As you step onto your right foot, your fingers pull superiorly on the suboccipitals on the right. Repeat this back-and-forth movement for two minutes or longer. 

Suboccipital Release No. 2

Move the client into a sidelying position to better access and release the suboccipital muscles. Grasp around the client’s head so your thumbs meet at the base of the client’s skull on the suboccipital muscles. Massage along the occipital ridge, making several passes with your thumbs. When you palpate areas of particular tension, compress the tight tissue with your thumbs and ask the client to flex their head forward. Follow this movement with your thumbs to stretch and release the tissue. 

Pillowcase Decompression

This technique creates space between the vertebrae, relieving pressure on the intervertebral discs and promoting proper cervical alignment. Fold a pillowcase into a narrow strip and ask the client to lift their head so you can place it under their mid-neck to maintain their cervical lordosis. Hold the pillowcase strip with both hands close to the client’s head, just above their ears, so your thumbs rest between their brows. 

Drop your body weight back to apply gentle traction to the cervical spine. Avoid intense pressure or jerking the pillowcase. Lean back slightly until you feel the client’s first restrictive barrier. Ask the client to shrug their shoulders toward their ears while you continue holding to a count of five. Relax and have the client relax. Reengage the pillowcase and lean back, applying light traction to the client’s second restrictive barrier, and repeat the shoulder shrugging process. Repeat the sequence a third time to complete the technique. 

Pulling It All Together

We’ve plunged into the world of the suboccipitals and explored the delicate interplay between the structures of the upper cervical spine. We’ve examined the far-reaching consequences of suboccipital imbalance and hypertonicity related to proprioception, head-righting reflexes, occipital neuralgia, stomach sleeper’s headache, and dural tension. 

MAT offers a holistic, comprehensive solution, incorporating thoughtfully sequenced techniques designed to release tension in the suboccipitals while considering the broader context of upper cross syndrome and forward-head posture.

These eight fundamental techniques come from a longer MAT cervical routine. These methods promote proper atlas and axis alignment, reduce tension, and improve cervical function. 

Digital devices will continue to dominate our lives and inform the stories the suboccipitals tell our hands. By staying informed and integrating effective techniques into our neck treatment, we can empower clients to find relief and make choices to improve their postural habits. 

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