In Headache, Manual Medicine, Muscular System, Neck Pain, Neck Pain, Shoulder Pain, Skeletal System, Upper Back Pain, Upper Crossed Syndrome, Upper Crossed Syndrome

The Sub-Occipital Release is a manual (or “hands-on”) therapy technique utilized to release the fascia and muscles surrounding and supporting the head and neck.  The best part – it’s simple, safe, and can easily be performed at home! You’ll need a partner to help.


Background & Indications

The Sub-Occipital Release helps to soften the fascia and muscle tissue in the sub-occipital area. This helps to open up the area between the C1 (Atlas) and C2 (Axis) vertebrae at the top of the neck and the base of the head, or occiput. The Sub-Occipital Release may be considered in the treatment of tension headaches, neck pain, shoulder pain and upper back pain. Additionally this technique can be utilized in individuals who have started to develop Upper Crossed Syndrome, a term used to describe the distorted posture of an individual whose shoulders are slumped and whose head and neck jut forward, a common posture in today’s society, possibly linked to our lifestyles, smart phones, and desk jobs. This posture is the result of chronic shortening of the sub-occipital muscles and can lead to headaches, as well as head and neck pain. The Sub-Occipital Release technique can be used to stretch and soften these muscles to improve pain and posture.

Relevant Anatomy

When healthy, fascia is a flexible, pliable, and strong tissue. However, physical trauma or stress can cause fascia to become tight and restricted. This is especially noticeable in areas where individuals hold tension; shoulders, head and neck. This area may become very stiff and individuals may suffer pain, restricted range of motion, and headaches due to the tight fascia and/or muscle tension. The Sub-Occipital Release technique focuses on releasing the fascia surrounding the skull to provide relief to individuals with pain, stiffness, or headaches.

The sub-occipitals are a group for four small muscles that attach at the C1 or C2 vertebrae at the top of the neck. Three of these muscles touch the base of the occiput which is the back of the skull. The sub-occipital muscles are responsible for head movement; rocking, tilting and rotating to either side. These muscles also stabilize the head as it sits on C1, which sits on C2. The sub-occipital area consists of thick muscles that are susceptible to becoming tense and tight. This technique can be utilized to stretch and soften the sub-occipital muscles and to allow more space into the upper cervical (neck) and occipital (base of skull) area.

Step-by-Step Instructions

For simplicity, we’ll assign two roles: patient and practioner. The patient is the person being treated, and the practioner is the friend, family member, or medical provider who is providing the treatment.

  1. The patient is on his or her back on a flat surface (bed, massage table, even the floor will do!) in front of practitioner.
  2. Practitioner is resting forearms on flat surface at the same level as the patient..
  3. Start at the thoracic and work up to the cervical spine with some light, gentle massage and soft tissue therapy to help relax the patient. [A good guideline: if it feels good, you’re doing it right! Avoid anywhere you feel a “pulse,” including the carotid area under the jaw.]
  4. As you work up the neck and cervical spine, you will eventually reach the bony ridge of the occiput.
  5. Once you reach the occiput or bony base of the skull, move your hands down ½-1 inch until you find the squishy soft tissue (muscles, fascia, etc.) at the top of the neck over C1 and C2.
  6. Cradle and put gentle finger pressure using only the fingertips up into sub-occipital space, this will gently lift entire head and neck. This should be about the same pressure you would use to lift a small, light object like a shoe or a pillow.
  7. Patient’s head and neck pressure will be placed on fingers.
  8. Continue soft, steady gentle pressure until tissue starts to release and soften. I recommend at least 30 seconds to one minute.
  9. As the tissue softens, the head will release back and rest on your palms.
  10. After the full release, you will relax your fingers and allow the patient’s head to rest in the palm of your hands.
  11. Take your time, nice and slow to open up the upper cervical and occipital space as much as possible.

Risks or Contraindications

A risk to be wary of in any deep tissue manual technique relating to the neck is a condition called Carotid Sinus Hypersensitivity (CSH). The carotid sinus is located at the division between the internal and external carotid arteries. The unintentional application of pressure to the carotid sinus in an individual with CSH can result in lowered pulse and a drop in blood pressure. CSH is an uncommon disorder but is something to be aware of when considering any deep tissue manual techniques in the neck area. I find it best to avoid this area completely when doing this technique.

Vertebrobasilar Insufficiency (VBI) occurs when vertebral arteries are compressed by head hyperextension or rotation, causing a reduction in blood flow to the brain. VBI can cause vertigo, dizziness, tinnitus, and disorientation. If a patient reports any of these symptoms during treatment, the treatment should immediately be stopped and the patient should be gently be brought to a normal position. There is a risk of VBI when applying pressure to the sub-occipital tissues, as in the Sub-Occipital Release.

Evidence Basis or Studies Supporting It

The Sub-Occipital release is a technique employed in schools of Osteopathic Medicine, physical therapy, and massage, among others. A study completed by The University of Valencia in 2012 evaluated the treatment of tension-type headaches with articulatory and sub-occipital soft tissue therapy. This study noted significant improvement of headache impact on patients after having 8 weeks of therapy. It is important to note that other treatments, such as chiropractic treatments, in the same cervical and occipital area have demonstrated patient improvement in pain and reduced tightness after treatment.

Additional Information

Video demonstrating the Sub-Occipital Release

Sub-Occipital Release Informative Video

Sub-Occipital Muscle Trigger Points Diagram

Detailed Anatomy of Sub-Occipital Muscles

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