The middle scalene is the largest scalene muscle, inserting via a broad tendinous attachment onto the superior surface of the first rib posterior to the subclavian artery groove. The brachial plexus roots pass between the anterior and middle scalene, making the middle scalene insertion a key landmark in interscalene anatomy.
The middle scalene tendon insertion defines the posterior border of the scalene triangle through which the brachial plexus exits. Interscalene nerve blocks are performed in this triangle. Hypertrophy of the middle scalene narrows the scalene triangle and compresses the brachial plexus in neurogenic thoracic outlet syndrome. Middle scalenectomy is the surgical approach to posterior scalene triangle decompression.
Brachial plexus compression between the anterior and middle scalene tendons from muscular hypertrophy or fibrosis, producing arm pain, paresthesiae, and hand weakness in a lower trunk distribution.
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