Soft Tissue Sore Spots!

I question a lot of dubious diagnoses that physios hand out in an attempt to explain pain or disability in people, such as pelvic torsions, over-active psoas, or gluteal amnesia. However, one sketchy diagnosis that I question a lot and that gets a lot of physios wound up is ‘myofascial trigger points’ or MTP’s for short, or more simply referred to as muscle knots.

Myofascial trigger points are believed to be small localised areas of muscle tissue that are adversely experiencing sustained periods of contraction, causing either painful muscle knots or taut bands located throughout our bodies. These are thought to occur either due to trauma, physical overload, or adverse postural stresses, however, I think this is bullshit.

Now, when I say I think trigger points are bullshit this is not to say I don’t think many people, myself included, don’t experience pain that is felt to be arising from our muscles when they are pressed or poked around a bit. When I say I think trigger points are bullshit I mean I think the theory about how small areas of our muscles stay adversely contracted causing pain and dysfunction is bullshit.

What I think is even more bullshit is that these so-called adverse muscle knots and bands need to be treated by pressing, poking, stabbing, or injecting them. I also think the term trigger point’ is bullshit, being potentially nocebic and harmful for some. Instead, I think these sensations should simply be called soft tissue sore spots which despite common assumption may have nothing to do with muscle knots.

The Start of Trigger Points

The theory of trigger points has been around since the early 1980s, with it first proposed by a US physician called Dr Janet Travell, who was an excellent and proficient Doctor achieving many great things during her career, including being the personal physician to John F Kennedy. Dr Travell along with her colleague Dr David Simons postulated that pain felt arising from muscles was due to small areas of sustained muscle fibre contractions believed to be caused by an adverse feedback loop between the muscle and its neural motor endplate.

From this theory, they described how trigger points can produce both local and referred pain in specific muscles and produced the now widely recognised trigger point maps and their famous red books titled ‘Myofascial Pain and Dysfunction: The Trigger Point Manual’ Volumes 1 and 2. These tomes were first published in 1983 and contained over 700 pages each yet only a handful of references, reflecting that these were largely based on theory and opinion and also highlighting the lack of research in this area back then.

However, these books became very popular, very quickly with doctors and therapists across many professions quickly accepting Dr Travell and Simons theories despite no research or evidence to support them. Now of course this was the early days and so can be forgiven, but since then a lot of research has been conducted on trigger points, and there is still NO robust evidence that has proven the existence of sustained muscle contractions, muscle knots, taut bands, and still NO valid way to detect these so called adverse trigger points!

So what are they then?

Although the small adverse muscle contraction is still the most popular theory for trigger points today there are alternative theories as to what may cause pain to be felt in our soft tissues. One such theory proposed back in 1994 by Drs Quintner and Cohen, two Australian rheumatologists and staunch trigger point critics is that perhaps these sore spots could be due to neuro-inflammation or neuro-vascular ischemia within or around our subcutaneous peripheral nerves. (ref).

These counter theories did, and still do, cause a lot of kickback from the die-hard muscle knot camps and there has been a fair bit of shit flinging on both sides over the years as can be read here and here. However, despite these arguments raging on, there still is NO robust evidence of what actually causes these painful sensations in peoples soft tissues.

For me, the neuro-inflammatory and/or vascular ischemic theory seems to be more plausible than muscle knots. This theory also helps explain why we are so bad and being able to locate muscle knots (because they don’t exist) and means that movement and activity rather than pressing or stabbing soft tissue sore spots would be a better treatment option.

Our nervous system, including our vast subcutaneous neural system, requires a lot of blood flow to keep it nourished and functioning effectively. All nerves need a large and undisrupted vascular supply and any disruption to a nerves blood flow will soon cause it to become pissed off, and when nerves get pissed off pain can quickly follow.

It is also important to remember that nerves have their own nerve supply, the nervi nevorum, and so nerves can and do express nociception, just as any tissue can as discussed here. This neural vascular ischemic theory is in my opinion, a far more rational explanation of why many suffer from soft tissue sore spots, but, more importantly, it also gives us an explanation as to why no one, and I mean no one, has been able to consistently or reliably find so-called muscle knots or taut bands.

Annoying Knots

It’s no secret that I annoy and frustrate many therapists for many different reasons, but one of the most common and easiest ways I annoyed many therapists is by questioning and challenging their self-perceived skills of palpation. Over the years I have had many disagreements with colleagues about trigger points who would occasionally grab me to feel a muscle knot they have just found in one of their patients, with them guiding my hand onto a patients muscle and say…

‘there you go Meakins, do you feel that… thats a clear and bloody obvious trigger point…?

I would rummage around for a bit, often with the poor patient wiggling and squirming underneath me in discomfort as I pressed ‘something’ that was clearly uncomfortable for them. But, I could NEVER say with any certainty that what I was pressing was an abnormal muscle lump, knot, or taut band.

I have also in the past tested a few of my colleagues who told me that they can feel adverse muscle knots back by asking them to see if they can feel one in a patient who I think I’ve found one in during my assessment. I’d tell my colleague that I would like their second opinion on a possible trigger point that I think I’ve found in the patient’s right shoulder or left leg and let them go to work, and about 90% of the time they would find it too.

However, what I didn’t tell them is that I actually didn’t feel anything unusual in my assessment and I just wanted to see if telling them that I did affected what they thought they could feel. Whenever I did this little sneaky test on my colleagues it always strengthened my conviction that most of what therapists think they can feel with palpation, is driven by… what they think they can feel.

When I tell other therapists that I honestly don’t think I’ve ever felt a muscle knot I either get looks of amazement and disbelief, or sneers of disgust and contempt, with some slowly backing away from me as if thinking they are going to catch my stupidity if they get too close. Yet it’s true, I honestly don’t think I have ever felt an abnormal adverse muscle knot or taut band.

Don’t get me wrong I have found abnormal lumps in people before, but these are usually lipomas, cysts, ganglions, or unfortunately other more serious things. I have also found and continue to find many, many, sore painful spots in many, many, people. But can I say with any certainty that these are adverse or abnormal muscle knots or taut bands… NOPE!

But it seems that the belief of muscle knots in people with pain is so pervasive and strong, and has become so routine and deeply ingrained into the therapy professions that anyone who says they haven’t felt them is classed as unusual, weird, or unskilled with many telling me that I need more training and practice in my skills of palpation! Well unfortunately for them I have been on many myofascial, soft tissue, trigger point, and dry needling courses, and I have had plenty of experience in searching for these damn muscle knots, pressing and prodding patients for well over a decade yet still I haven’t conclusively found one.

I’m Not Alone

However, what does give me some comfort and reassurance that I’m not an unskilled ham-fisted numpty with these damn muscle knots is that I am not alone in being unable to find them, with some of the worlds leading experts in trigger points also being unable to find them, including Dr David Simons of Travell and Simons

In this little known study, Dr Simons along with four other leading experts in trigger points attempted to demonstrate their reliability in locating them in three groups of subjects. The first group were those already diagnosed as having trigger points, the next group were diagnosed with Fibromyalgia so had sore spots but no muscle knots, and finally, there was a healthy control group who were both muscle knot and pain-free.

All the examiners were blinded to the subject’s status and were not allowed to talk or interview them, only examine them with palpation and attempt to locate the subjects with the trigger points… which they failed to do spectacularly. In fact, they were only able to identify 18% of the subjects with muscle knots but ‘found’ muscle knots in the healthy pain-free control group more than twice as much!

This study was an unmitigated disaster for the trigger point proponents as it questions both the reliability and validity of trigger points, because if the worlds leading experts can’t find them what chance do the rest of us have? This paper was almost not published due to some serious conflict with the authors and some rather dubious attempts to fiddle the data, which to his credit the lead author Fred Wolfe very honestly and openly talks about here.

Since this paper, there has been a lot more research conducted demonstrating the complete lack of clinical reliability to find muscle knots. For example, this paper by Hsieh shows that even after training, chiropractic students cannot find muscle knots in the trunk or lower limbs. Next, a systematic review in 2008 and another one in 2009 highlights the poor methodology, design, and bias in nearly all of the research conducted on trigger points and strongly questions the validity and reliability of the whole muscle knot theory.

This issue of poor research in the trigger point field is further demonstrated in a systematic review and meta-analysis by Kietrys in 2013 here that looked at the effectiveness of Dry Needling for Trigger Points in the Upper Trapezius. Although the conclusions look promising there are plenty of issues about the quality of the papers included in this review, a classic case of if you review garbage, you will still only find garbage, as discussed here on Body In Mind

So the awkward question we have to ask to those that still think that these soft tissue sore spots are muscle knots is why in the last 40+ years hasn’t there been any good, robust, well-designed research that can demonstrate that we can find them? Well, again that comes back to my earlier point that these soft tissue sore spots are NOT adverse or abnormal muscle knots.

Conclusion

So that’s my look at muscle knots and trigger points, and how I believe many therapists think they can feel things based on what they think they can feel. As I have tried to show there are alternative explanations for trigger points, but it must be acknowledged that these alternative theories are just that, theories.

However, there are some difficult and awkward questions for those who do believe in muscle knots, such as why can’t we find them, and if we can’t find them, how the hell are you supposed to treat them. Also how the hell does poking a muscle knot with a needle help it relax, the last time I checked, sticking needles into muscles and creating more trauma doesn’t cause them to relax or reduce trauma.

And even more perplexing, is how the hell can a muscle knot be treated with a method believed to INCREASE blood flow to it such as dry needling is said to do, but also be treated by a method such as ischemic digital pressure applied with fingers, knuckles or elbows believed to DECREASE blood flow to it?

As always thanks for reading

Adam

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  1. Sorry if this sounds a bit fanboyish in some ways and goes on a bit in others.
    Some nice research and comparison, very instructive while at the same time supporting some of the convictions I’ve built up over the years.
    There are two possible cause sets for spot pain (whether with physical symptoms or not)
    1) misfire
    2) trauma.
    There are the following possible physical symptoms
    1) Swelling
    2) Impairment of movement
    3) Excess heat
    4) Discolouration
    There is the following Neural symptom
    Pain
    There may be one of the following
    Excess sensation
    Unexpected lack of sensation
    Involuntary muscle movement
    Inability to perform voluntary muscle movements
    The traditional Physio/Massage and Strength/Fitness techniques are as follows
    1) Exercise below acute pain threshold
    2) Passive movement
    3) Heat/Cold
    4) Compression
    5) Stretching
    6) Massage
    Each seems to me quite likely capable of one or more of the following
    1) resetting a misfire by stimulation/activation
    2) reducing swelling by stimulation of capillary action and/or direct muscle action
    3) provoking a superior level of general nerve/muscle function and development
    4) stimulation of blood flow through the cardiovascular system which is generally held to be a good thing
    5) taking cells though their range of normal states – relaxation, exertion and response to heat, cold and touch – rather as one often does (and, importantly, this is often successful) with a machine that has developed a minor fault.
    Forced abnormal movements such as most of the TPT I’ve seen and stabbing such as dry needling and acupuncture don’t strike me as likely to provide any benefit at all except to the instructor and practitioners bank balance.

  2. First of all, what a great read about a less controversial topic that so many people just take for granted! What are “trigger points”? And as a clinician, I mostly want to know how to treat them! As per your questions regarding constricting vs. promoting blood flow, I think the answer lies in the sweet spot in properly utilizing both techniques. Personally, I use HawkGrips for Instrument Assisted Soft Tissue Mobilization (IASTM) to promote blood flow and break up adhesions. My patients love this treatment, especially on their upper traps… And the “trigger points” they have there!
    One of the theories behind IASTM is to induce a controlled inflammatory response to promote healing. The instruments “comb” through soft tissue and resonate tissue irregularity that is easy to feel! Let me know if you would like to discuss further!

    • Hi Trista
      First thanks for your comments, but there are some things in your message that just don’t add up
      I hear the explanation (or excuse) of creating controlled inflammation to produce healing to justify lots of so called therapeutic treatments eg Prolotherapy, PRP, deep tissue massage and now your IASTM
      The questions I also ask is 1) is inflammation and its chemical mediators and materials really needed at this stage of the patients injury 2) will the inflammatory millieu do anything significant even if it is needed and 3) how the hell do you control it externally, it either happens or not, you have no control over it!
      The best explanation of why these types of treatment reduce pain being felt is simple noxious inhibitory control by creating pressure and pain to elevate pain via peripheral and central neural processes, effects of blood flow, inflammation, scar tissue is all inconclusive and hearsay and if I am being so bold more about marketing and sales pitches rather than science
      Cheers
      Adam

  3. Why does it matter whether we call them trigger points or something else? Even if you don’t think you can palpate these problem areas to find muscle knots, the patient knows when a sore spot has been located. The stimulation of blood flow to these areas, whatever we call them, seems to be therapeutic. And what about this: http://www.ncbi.nlm.nih.gov/pubmed/19163983

    • It matters as we have an ethical responsibility to inform the patient to the best if out ability what is happening and why. Claims of knots etc are unfounded and inaccurate.
      And I’m afraid there is just no evidence of any increase in blood flow to anything other than the superficial layers of the skin with ANY type of manual therapy.
      And that sonography paper is very very flawed and the results haven’t been repeated since 2008 despite attempts and I discuss that in my review of trigger points here http://m.bjsm.bmj.com/content/49/6/348.short?rss=1

    • Hi Kyle
      Thanks for the comments and the great read!
      My confirmation bias was nodding along furiously and thoroughly enjoyed it, well done…
      Trigger points, schmigger points

  4. I really enjoyed your post. I have worked in front of a computer for 15 years and am sure I picked up some bad habits. When a therapist feels my neck or traps they mention lumps, ropey muscles and trigger points. I can feel very sore spots and “knots” when I press on them but deep tissue massages, dry needling, poking and prodding haven’t helped one bit. Headaches and neck pain are symptoms but all imaging looks good.
    So two questions, do you suggest strengthening the traps could have a positive impact?
    Also, if the tenderness/pain is due to a neural issue, and I understand it is just speculation at this point, but if it is then what can be done to try and correct the “misfiring” or “dysfunction” of the nerve and the brains response?
    Thanks again for your articles.
    Will

    • Hi Will
      Yes I would say give upper trap strengthening a go, just ease into any nee exercise gradually
      And yes it could also be a neural pain due to a traction effect to the neural tissue running through the weak and lengthened upper traps

  5. I found your blog while looking for evidence of the efficacy of the treatment I am currently receiving from my Physiotherapist; she diagnosed the muscles of my right leg and hips as being extremely tight to the point of twisting my pelvis forward and lengthening my right leg beyond my left. She has been doing exactly what you talk about, feeling for trigger points and then pushing on them to “release” them, also suggesting I do the same to myself at home with a tennis ball. Is this a legitimate method of releasing muscles or more pseudoscience? I can’t seem to find any studies about this issue an am very intrigued now!

    • I’m sorry to say but it sounds like your therapist has fallen victim (like many do) for the plausible pseudo science explanations of why things hurt!
      Pelvis don’t get twisted, everybody had one leg shorter/longer than the other and trigger points ie knots in muscles don’t exist!
      Pain is released by pressing these areas because pain inhibits pain, also due to other non specific factors.
      Keep moving, stay strong and everything will be fine!

  6. I really admire your blunt honesty when refusing to confirm the presence of something that you do not detect. I am interested in your opinion on this related topic. I have had support from many physios over recent years. Most were excellent. However two in private practice had a style of presenting themselves as gurus with their own special approach – and the same solution given to all. What they also had in common was the practice of telling the patient that “a certain point (on leg, arm) hurts here doesn’t it?” When i honestly said it didn’t, in both cases, the therapist became agitated at being contradicted and pressed harder until it did. In one case causing much bruising. But as the patient, or client, am i not correct to give honest answers?
    I am guessing that their forceful personalities tend to deter the majority of patients from contradicting their statements – and so they start to believe their own delusions of insight – in a circle which may have led to their arrogant natures! Anyway, honesty and is a real virtue and you are a much better therapist as a result.