Muscle:Platysma

Platysma is a broad, thin sheet of subcutaneous muscle covering the anterior neck, extending from the lower face to the upper chest. Its trigger points (TrPs) produce a characteristic prickling pain over the lateral mandible and lower face — a sensation of multiple pinpricks that is distinct from neurological tingling and is often deeply alarming to patients and clinicians alike. Platysma TrPs are virtually always secondary to TrPs in the sternocleidomastoid–scalene family and rarely occur in isolation.

Anatomy

The platysma is a cutaneous muscle whose fibres lie entirely within the subcutaneous fascia of the lower face and neck:

• Above — fibres interlace with the orbicularis oris; others attach to the corner of the mouth, other facial muscles, and the lower margin of the mandible
• Below — fibres attach to the subcutaneous fascia of the upper thorax

The platysma overlies the sternocleidomastoid in parallel. TrPs typically develop in relation to SCM involvement. Active TrPs are most commonly found overlying the SCM muscle belly; a TrP just above the clavicle may refer hot prickling pain across the front of the chest.

Histologically, the platysma's fibre characteristics more closely resemble limb muscles than do other facial muscles — its type I and IIA fibre proportions and diameter measurements are closer to limb norms.

Innervation: Facial nerve (cranial nerve VII), cervical branch.

Primary actions:

• Pulls the angle of the mouth downward
• Draws the thoracic skin upward
• Becomes active when widening the aperture of the already open jaws (confirmed by electromyography)
• Not active during swallowing or neck movements

Referred Pain Pattern

Active TrPs in the platysma produce a distinctive prickling pain — felt as multiple simultaneous pinpricks — over the lateral surface of the mandible and the skin just below it, on the same side (Fig. 13.1C, Travell & Simons Vol. 1, 2nd ed.).

A TrP located just above the clavicle may refer hot prickling pain across the front of the chest.

The prickling quality is the hallmark. It is not like the tingling caused by an electric current (which typically denotes neurological origin), but rather a superficial cutaneous pricking sensation. This distinction is clinically important for reassuring patients and avoiding neurological misattribution.

Activation and Perpetuating Factors

• Satellite activation from SCM and scalene TrPs — platysma TrPs are activated secondarily by TrPs in the sternocleidomastoid–scalene family of muscles, which the platysma overlies; this is the dominant mechanism
• Rarely primary — platysma TrPs are rarely, if ever, seen in the absence of TrPs in the SCM, scalene, or masticatory muscles on the same side
• Forward head posture — perpetuates SCM and scalene TrPs, which in turn sustain platysma satellite activity

Clinical Examination

Symptoms

• Prickling facial pain over the lateral jaw and mandible, as described above
• When platysma prickling pain co-occurs with headache from SCM TrPs, patients and their physicians are often greatly concerned — the combination can suggest neurological pathology
• Chest prickling from a supraclavicular TrP is occasionally reported

Patient Examination

No specific postural sign is pathognomonic for platysma TrPs. However:

• Always examine the sternocleidomastoid, scalene, and masticatory muscles on the same side — these are the key TrP sources
• Platysma TrPs are rarely present without active TrPs in at least one of these muscles

Trigger Point Examination

(Fig. 13.4, Travell & Simons Vol. 1, 2nd ed.)

1. Seat the patient and have them tip the head back far enough to tighten the platysma, bringing the muscle under slight tension
2. The examiner pinches successive transverse lines of skin across the muscle fibres, approximately 2 cm (1 inch) above the clavicle, rolling the skin and platysma between the digits
3. Rolling the skin and platysma between the digits usually sets off the referred prickling sensation in the lateral face — this is the characteristic positive finding
4. A palpable twitch response of the band is likely to be felt during this examination, even though visible local twitch responses are not readily observed

Note: When injecting the underlying SCM muscle, one may accidentally encounter a platysma TrP and evoke the referred facial prickling. The patient may react with alarm to this unexpected sensation — explain its cause immediately.

Nerve Entrapment

No nerve entrapments have been observed due to active TrPs in the platysma.

Differential Diagnosis

• Neurological tingling — the prickling of platysma TrPs feels like pinpricks, not the electric tingling of peripheral nerve dysfunction; tingling with a dermatomal or glove-and-stocking distribution, or tingling that is constant and progressive, warrants neurological referral
• Trigeminal neuralgia — lancinating paroxysmal pain with trigger zones, versus the sustained prickling of platysma TrPs
• Herpes zoster (shingles) — prodromal burning or prickling in a dermatomal distribution may resemble platysma referral early in the course; presence of vesicles, dermatomal distribution, and systemic symptoms distinguish zoster
• TMJ syndrome — patients with combined platysma and masticatory TrPs often have trouble chewing and swallowing, leading to a TMJ dysfunction diagnosis; TM joint dysfunction should be ruled out, and the masticatory muscles examined for TrPs
• Anxiety-related facial symptoms — the combination of facial prickling and headache is frequently attributed to anxiety or somatisation before the myofascial source is identified

Treatment

Trigger Point Release

Spray and Stretch

Spray and stretch is usually more effective for the platysma than for the orbicularis oculi or zygomaticus major because an adequate stretch can be achieved:

1. Seat the patient with the arm on the affected side anchored (to fix the lower attachment)
2. Turn the patient's face to the side opposite the involved muscle
3. Extend the head and neck to lengthen the platysma
4. Apply vapocoolant spray upward along the line of the platysma fibres, covering the muscle and its referred pain pattern with parallel sweeps
5. Caution: spray only while the patient is exhaling. Patients with asthma or other respiratory conditions should use ice stroking instead.
6. On reexamination, if TrPs still show activity, apply firm sustained pressure to the TrP and maintain it as the taut band releases

For a combined stretch release that includes the platysma together with the SCM, refer to Figure 8.5 in Travell & Simons Vol. 1.

Trigger Point Pressure Release

After spray, if TrPs remain active, apply firm digital pressure directly to the TrP and sustain it until the taut band releases.

Trigger Point Injection

Injection is rarely required to clear the platysma of active TrPs — most cases respond to spray and stretch or pressure release.

When injection is used:

1. Identify the TrP by the rolling skin technique (see Trigger Point Examination above)
2. Inject precisely into each TrP
3. Follow immediately with several active contractions of the muscle (patient pulls corner of mouth downward, then relaxes), followed by relaxation in the lengthened position

Acupuncture needle technique (Lapeer): Dry needling with a 34-gauge acupuncture needle inserted to the point of lowest skin resistance, to a depth reported as painful by the patient, with four treatments of 20 minutes each over 10 days, has been reported to resolve chronic platysma pain.

Corrective Actions

The essential corrective strategy is addressing the key TrPs in muscles responsible for these satellite foci:

• Sternocleidomastoid — the primary driver; treat SCM TrPs first
• Scalenes — co-active with SCM in perpetuating platysma TrP activity
• Masseter, temporalis, pterygoids — masticatory muscle TrPs on the same side should be inactivated

Following treatment, the patient should perform regular passive stretching exercises (neck extension with contralateral rotation) and resume full activity to prevent recurrence.

Satellite Trigger Points

Platysma TrPs are themselves satellites. The muscles to examine as primary key TrP sources:

• Sternocleidomastoid — the dominant key muscle
• Scalene muscles — co-activate with SCM
• Masseter — masticatory involvement
• Temporalis — masticatory involvement

Related Pages

• Face and Jaw pain region (coming soon)
• Sternocleidomastoid — primary key TrP muscle driving platysma satellites
• Scalene muscles — co-active perpetuating muscles
• Zygomaticus major — co-involved facial muscle
• Orbicularis oculi — co-involved; nasal and upper lip pain
• Buccinator — co-involved; subzygomatic jaw pain

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 13.
• Lapeer GL. Postsurgical myofascial pain resolved with dry-needling. Treatment protocol and case report. J Craniomandib Pract 7(3):243–244, 1989.