The neck contains many vital structures and connects the head to the torso. The skeleton of the neck includes 7 cervical vertebrae, the hyoid bone, manubrium, and clavicles. The neck separates into anterior and posterior triangles divided by the sternocleidomastoid muscle. The triangles contain muscles, vessels, and nerves. Conditions like torticollis can cause neck twisting that is treated with physiotherapy including massage, stretches, and exercises to improve range of motion.

1. Anatomy Of NECK
Submitted by:- Sakshi Upadhyay
MPT Sports

2. Introduction
• The neck is the bridge between the head and the rest of the body.
It is located in between the mandible and the clavicle, connecting
the head directly to the torso, and contains numerous vital
structures.
• Structures contained within the neck are responsible for
breathing, speaking, swallowing, regulation of metabolism,
support and connection of the brain and cervical spine, and
circulatory and lymphatic inflow and outflow from the head.

3. Bone of the Neck
• The skeleton of the neck is formed by the cervical vertebrae, hyoid bone,
manubrium of the sternum, and clavicles.
• These bones are parts of the axial skeleton except the clavicles, which are
part of the appendicular skeleton.

4.  Cervical Vertebrae
• 7 cervical vertebrae form the cervical region of the vertebral column, which
encloses the spinal cord and meninges.

5.  Hyoid Bone (Hyoid)
• Lies in the anterior part of the neck at the level of the C3 in the angle between
the mandible and the thyroid cartilage.
• Suspended by muscles that connect it to the mandible, styloid processes,
thyroid cartilage, manubrium, and scapulae.
• Does not articulate with any other bone.

6. • The hyoid consists of a body and greater and lesser horns and the lesser horn
is the attachment for the stylohyoid ligament).
• Functionally, the hyoid serves as an attachment for anterior neck muscles and
a prop to keep the airway open.

7. Fascia of the Neck
• Structures in the neck are surrounded by a layer of fascia but the two main divisions
are superficial fascia and deep cervical fascia.
 The superficial cervical fascia extends
from the head down to the thorax and axillae.
In the neck, it contains the superficial
lymph nodes, cutaneous nerves, external
and anterior jugular veins, and
the platysma muscle. It is arranged loosely to
allow for neck movement.

8.  The deep cervical fascia subdivides into the superficial layer of deep cervical
fascia, the middle layer of deep cervical fascia, and the deep layer of deep
layer of deep cervical fascia.
• The superficial layer of deep cervical fascia, or investing layer, lies between the muscles of the
neck and the superficial cervical fascia, encircling the sternocleidomastoid and trapezius muscles. It
attaches inferiorly to the scapula, clavicle, and manubrium. Superiorly, it attaches to the mandible,
mastoid process, superior nuchal line, and external occipital protuberance.
• The middle layer of deep cervical fascia, or the pre tracheal layer, runs from the mediastinum
inferiorly to the skull base superiorly. It has a muscular and visceral division. The muscular division
encloses the strap muscles, sternohyoid, sternothyroid, omohyoid, and thyrohyoid muscles. The
visceral division encloses the larynx, pharynx, esophagus, thyroid, parathyroid glands, trachea, and
recurrent laryngeal nerve.
• The deep layer of deep cervical fascia, or prevertebral layer, runs from the skull base to the
mediastinum. Its two divisions are the alar and prevertebral layers. These layers surround the deep
muscles of the neck and the cervical vertebrae, forming part of the retropharyngeal space.

9. Triangle of the Neck
• The neck separates into two triangles: anterior and posterior, with these
divided into additional triangles and anatomic areas.
• The anterior triangle is surrounded inferiorly by the sternal notch and
clavicle, laterally by the sternocleidomastoid, and medially by the trachea,
thyroid, and cricoid cartilages.
• The posterior triangle is bordered posteriorly by the trapezius muscle,
anteriorly by the sternocleidomastoid muscle, and inferiorly by the clavicle.

11.  Posterior triangle
 This is formed by :
The Sternocleidomastoid muscle-anteriorly.
The Trapezius muscle-posteriorly.
The Clavicle-inferiorly.
The apex of the triangle is formed by the occipital bone.
 The ROOF of the posterior triangle is formed by:
Skin
Superficial fascia
Platysma
Investing layer of the deep cervical fascia

12. • The FLOOR of the triangle is formed by the following
muscles from above downwards:
Splenius Capitis
Levator scapulae
Posterior scalene
Middle scalene
Anterior scalene

13. Subdivisions of the posterior triangle
• The posterior triangle is further divided into two smaller
triangles by the Inferior belly of the Omohyoid muscle .
These are the Supraclavicular triangle and Occipital
triangle.
1. Supraclavicular triangle - It is formed by the Inferior
belly of the Omohyoid, the Clavicle and
Sternocleidomastoid muscle.
2. The Occipital triangle is formed by the Inferior belly of
the Omohyoid, the Trapezius muscle and
Sternocleidomastoid muscle.

14. Nerves and Plexuses of the Posterior Triangle
• Spinal accessory nerve
• Branches of Cervical plexus
• Roots and trunks of
• brachial plexus

15. Muscles of the Posterior Triangle
• Sternocleidomastoid
• Splenius capitis
• Levator scapulae
• Scalenus medius
• Scalenus anterior (may or
may not be present)
• Trapezius

16. Arteries of the Posterior Triangle
• Subclavian (3rd part)
• Superficial cervical & suprascapular
(branches of thyrocervical trunk, a
branch of 1st part of subclavian artery)
• Occipital, a branch of external carotid
artery

17. Veins of the Posterior Triangle

18.  Anterior Triangle
• BOUNDARIES:
Anterior border of the SCM muscle
Midline of the neck
Inferior border of the mandible
• ROOF:
Skin
Superfacial fascia and platysma muscle
Investing layer of deep cervical fascia

19. SUBDIVISIONS OF ANTERIOR TRIANGLE
• The anterior triangle is divided into four smaller triangles:
SUBMENTAL TRIANGLE
SUBMANDIBULAR TRIANGLE
CAROTID TRIANGLE
MUSCULAR TRIANGLE

20. 1.SUBMENTAL TRIANGLE formed by the :
anterior midline of neck
hyoid bone
anterior belly of digastric muscle
2.SUBMANDIBULAR TRIANGLE formed by:
Inferior border of the mandible
Anterior belly of the digastric muscle
Posterior belly of the digastric muscle
3.CAROTID TRIANGLE formed by :
Superior belly of the Omohyoid muscle
Sternocleidomastoid muscle
Posterior belly of the digastric muscle
4.MUSCULAR TRIANGLE formed by :
midline of the neck
superior belly of the Omohyoid
sternocleidomastoid muscle

21. Muscles of the Anterior Triangle
• Suprahyoid muscles : (Digastric , Mylohyoid,
Stylohyoid, Geniohyoid). These elevate the
hyoid bone , and the floor of the mouth ,
and depress the mandible .
• Infrahyoid muscles : (Sternohyoid,
Sternothyroid, Thyrohyoid, Omohyoid).
These depress the hyoid bone and
the larynx.

22. Vessels and Nerve of the Anterior Triangle
• VESSELS:
carotid system(CCA,ICA, ECA)
Internal Jugular vein
• NERVES:
Cranial nerves 7,9,10,11,12
Cervical plexus

23. Muscles of the Neck
• Sternocleidomastoid
• Scalene Muscles
Anterior, Middle and Posterior
• Masseter Muscle
• Splenius Cervicis Muscle
• Levator Scapulae Muscle
• Trapezius Muscle

24.  Sternocleidomastoid
• Action
Bilateral: Extends the head, assists in
respiration when the head is fixed
Unilateral: Tilts the head to the same side,
rotates the head to the opposite side
• Origin
Sternal head: Manubrium
Clavicular head: Medial third of the clavicle
• Insertion
Mastoid process and superior nuchal line
• Innervation
Accessory nerve and direct branches from the
cervical plexus (C1-2)

25. Examine Sternocleidomastoid
• Position of the patient is in Supine
• Location: the mastoid process, medial
• clavicle and
the top of the sternum
• Ask patient to raise his head very
slightly off the
table as you palpate SCM
• Palpate along the borders of the SCM
• Follow it behind the earlobe and then
down to the clavicle and sternum.

26.  Scalene muscles
• Anterior scalene
• Middle scalene
• Posterior scalene
• Actions of scalenes muscles
Unilaterally: Laterally flex the head and
neck to the same side, rotate head and neck to
the opposite side
Bilaterally: Elevate the ribs during inhalation,
flex the head and neck

27. Anterior scalene
• Origin
TP of 3rd through 6th cervical vertebrae (ant.
tubercle)
• Insertion
1st rib
• Innervation
Cervical and brachial plexus (C3-6)

28. Middle scalene
• Origin
TP of 3rd through 7th cervical vertebrae (post.
tubercle)
• Insertion
1st rib
• Innervation
Cervical and brachial plexus (C3-6)

29. Posterior scalene
• Origin
TP of 5th through 7th cervical vertebrae (post.
tubercle)
• Insertion
2nd rib
• Innervation
Cervical and brachial plexus (C3-6)

30. Examine Scalenes
• Position of the patient is in Supine
• Cradle the head to allow for
easier palpation
• Place your finger pad along the
ant. and lat. sides of the
neck b/w SCM and trapezius.

31. Masseter
• Position of the patient is in Supine
• Location: zygomatic arch and
angle of the mandible
• Place your fingers b/w these
bony landmarks and
palpate the surface of the masseter
• Ask pt. to alternately clench and
relax her jaw

32. Splenius muscles
• Action
Entire muscle bilateral contraction extends the
cervical spine and head, unilateral contraction
flexes and rotates the head to the same side
• Origin
Splenius cervicis Spinous process of T3-T6
vertebrae
Splenius capitis Spinous process of C3-T3
vertebrae
• Insertion
Splenius cervicis Transverse process of C1-2
Splenius capitis Lateral superior nuchal line,
mastoid process
• Innervation
Lateral branches of dorsal rami of spinal nerves
C1-6

33. Clinical Anatomy
Torticollis
• Torticollis, also known as wry neck, is a dystonic
condition defined by an abnormal, asymmetrical head
or neck position, which may be due to a variety of causes.
• The term torticollis is derived from the Latin words
tortus for twisted and collum for neck.

34. Signs and Symptoms
• Torticollis can be a disorder in itself as well as a symptom
in other conditions.
• Other symptoms include:
• Neck pain
• Occasional formation of a mass
• Thickened or tight sternocleidomastoid muscle
• Tenderness on the cervical spine
• Tremor in head
• Unequal shoulder heights
• Decreased neck movement

35. Torticollis may lead to additional problems :
 Flattening of the skull (plagiocephaly or brachycephaly) in
infants.
 Movement that favors one side of the body, affecting the
arms, trunk, and hips. This can lead to strength imbalances,
such as an elevated shoulder and side- bending of the trunk.
This movement pattern can lead to delayed gross motor
development.
 Developmental hip dysplasia.
 Scoliosis.
 Limited ability to turn the head to see, hear, and interact with
surroundings, which can lead to delayed cognitive
development.
 Delayed body awareness or lack of self-awareness and
interaction.
 Difficulty with balance.
 Asymmetrical vision changes.

36. Diagnosis
• General History taking
• Birth History
• History of Trauma
• Neurological examination
• X-ray of cervical spine
• MRI
• USG - Muscular tissue, Colour Histogram
• Optometrist evaluation

37. Assessment :
• Observation of any asymmetries including facial, cranial, neck and positional preference
and presence of plagiocephaly.
• Observation of skin creases.
• Observation of infant in developmentally appropriate positions to detect asymmetry and
screen developmental milestones.
• Cervical active and passive range of movement testing.
• Upper and lower limb ROM screen, checking for hip dysplasia, which can be associated
with CMT, and spine asymmetry.
• Pain at rest and during movements.
• Palpation of sternocleidomastoid for size and elasticity and presence of mass.
• Screen of visual tracking.
• Screen muscle tone.
• Identification of Red flags and appropriate onward referral:
1. poor tracking
2. abnormal muscle tone
3. other features inconsistent with CMT
4. poor progress with treatment

38. Physiotherapy Management
Goals
• Improve child's ability to turn head between right and left
sides
• Improve child's ability to bring chin to chest
• Improve child's ability to orient their head to midline against
gravity
• Encourage child to lift head against gravity while lying on
stomach
• Allow child to experience proper weight shifting during
developmental activities including sitting, rolling, creeping and
walking

39. Early mild cases
 Children with a mild degree of deformity reporting early for
the treatment can be managed with physiotherapy.
 The physiotherapy procedures employed are:
I. Evaluation: Careful evaluation of ROM and the degree of
deformity.
II. Massage: Massage can relax the muscle preceding the
stretching maneuvers.
III.Thermo Therapy Modality: Carefully administered thermo-
therapy modality induces relaxation.
IV.Passive movements: The child is placed in supine position
with head beyond the edge of the table with the neck in
extension by positioning a pillow under the thoracic region;
Shoulders are stabilized by an assistant.

40. • To attain relaxation, all the movements of
the cervical spine are done in a form of slow
relaxed passive movements.
• This should be followed by sustained passive
stretching to the affected sternomastoid.
E.g. when the right sternomastoid is
involved the head should be gradually
bent inside flexion to the left, held there for a while
and then rotated gradually to the right. Try to gain as
much overcorrection as possible by applying gradual
traction to gain further stretching.

41. • Maintenance of Correction: Once
the correction is achieved.
It has to be maintained by passively
holding or keeping a sandbag.
E.g: Kineso taping, Cervical Brace,
Cervical collars.
• The same maneuver can be repeated during the subsequent
visits.
Active correction is best achieved by assisting the child head
to follow an object moved in the proper arc of correction. The
bright-colored sound producing object is ideal to attract the
child attention. – PNF: patients with neck extension can be
used to an advantage with emphasis on stretch and traction.

42. Post surgical PT management
• Hot packs for pain relief.
• Active movements of sternocleidomastoid to prevent post
surgery weakness.
• Free active movements in the direction of correction
followed by resistive exercises.
• Self correction in front of mirror.
• Specially molded cervical collar and maintenance of
correction during sleep.