Soft Tissue Sore Spots of an Unknown Origin!

I question a lot of the dubious diagnoses that are believed to cause of pain or dysfunction in this profession. One that I question more than most is the well known and popular diagnosis of ‘trigger points’. These are believed to be small adverse muscle knots or taut bands dotted throughout our bodies due to trauma, or overload, or postural stresses and strains. However, I think this is all a load of nonsensical bull shit.

Now this is not to say I doubt that many patients suffer with pain when pressed or poked somewhere on their bodies. I have had many patients moan, yelp, shout out when I poke or press them. However, the explanation that these sore spots are knots or bands in muscles or fascia is what I doubt.

Soft Tissue Sore Spots

Also the term ‘trigger point’ is misleading, inaccurate, and I think potentially nocebic. Instead, I think these painful areas should be called ‘Soft Tissue Sore Spots’ (STSS) or perhaps even more accurately ‘Soft Tissue Sore Spots of an Unknown Origin’ (STSSOAUO).

Now don’t worry I haven’t gone completely mad, and I am only joking in suggesting that we should use another ridiculous lengthy acronym, of which we have far too many of already in this business. The point I am trying to make is that many associate the term ‘Trigger Point’ to mean ‘muscle knot’ when this has never been proven!

The theory of muscle knots as a cause of pain has been around since the early 1980’s. The theory was first proposed by the eminent and influential US physician Dr Janet Travell, who was JKF’s pesonal physician no less. She teamed up with another Doctor called David Simons and together produced the famous trigger point books. These books and the muscle knot theory was soon quickly adopted by many practitioners, despite no peer review, no research or evidence, just a theory by two clinicians that is now widely accepted as fact. However, despite many claims over the decades and years of searching, the uncomfortable truth is there is NO robust or reliaboe evidence that has proven muscle knots exist or are a source of pain!

So what are they then?

Well there is an alternative theory about what causes soft tissue sore spots that is not as well-known as muscle knots. That is perhaps these sore spots are due to issues with the sub cutaneous peripheral nerves. A rheumatologist called John Quintner was the first to propose the idea of subcutaneous peripheral nerves as a source of these soft tissue sore spots in his 1994 paper freely accessible here.

Why these nerves are a source of pain isn’t fully understood, and recognised, but it is hypothesised that it could be either direct macro trauma, or micro trauma from repeated postures and stresses to the nerves blood supply which is vast and complex, as described in this paper here.

It should be remembered that our neural system, including our sub cutaneous neural system, requires a lot of fuel to keep it functioning effectively and it is a veracious consumer of energy. Therefore it needs a huge vascular supply to feed it, and any slight disruption to any nerves blood flow will soon cause the nerve to become distressed, and will soon be perceived as a threat, and so 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, and has been discussed in a paper here by Geoffrey Bove another rheumotologist. This theory of nervous tissue distress, in my opinion, is a far more logical, rationale and simpler explanation of why many suffer with soft tissue sore spots. But, more importantly it also gives us an explanation of why know one, and I mean know one, has ever been able to consistently or reliably find these so called muscle knots or taut bands.

Annoying

I have in the past, and continue to do so, annoy and frustrate many therapists including many of my tutors, mentors and peers when it comes to trying tk find these so called muscle knots. I have had many a tutor or colleague invite me to feel a ‘knot’ in a patients muscle that they are convinced they have just found. They would direct my hand onto a patients back, leg, shoulder, and say

‘feel that Meaks, thats a bloody trigger point, ok…?

I would press and rummage around for a bit, with the poor patient wiggling and squirming underneath me as I pressed ‘something’ that was clearly sore for them. But could I ever say I could feel an abnormal lump, knot or taut band? Nope, and I would say so, pissing off the other therapist desperate to convince me that there was something there, and confusing the patient who now isnt sure what to believe! 

In fact I will quite confidently say…

I have NEVER felt a muscle ‘knot’

Now, I have felt muscle spasm and increased tone, but never a ‘knot’, and when I say this to therapists and doctors, I often get looked at as if I am mad or crazy, with many therapists slowly backing away from me as if they are going to catch my stupidity like a disease. It seems that the beleif in muscule knots has become so deeply ingrained into ojr profession that anyone who says they can’t or haven’t felt muscle knots are classed as stupid or weird, and many therapists sneer at me with scorn and disgust, telling me that I clearly need more training and that old chestnut of I just need more experience!

Well maybe they’re right, maybe I do need more training, I’ve always believed I have sausage fingers when it comes to palpating things. But please believe me when I say I have had plenty of experience in searching for these damn muscle knots. I have been pressing and prodding patients for well over a decade looking for these knots, and I estimate I must have palpated 25,000 people in my career, yet I still haven’t conclusively found one single muscle knot… yet.

And before you ask, yes I have been on the ‘official’ training courses designed to help find these ‘trigger points’, and I have even attained a so called ‘qualification’ in the Dry Needling method that is supposed to treat them, all in an attempt to find these bloody trigger points.

Not alone

But what does give me some reassurance that im not a complete numpty with these trigger points is that I am not alone in being unable to find these trigger points. Even the worlds leading experts in trigger points can NOT find them either, including David Simons of Travell and Simons, as highlighted in Fred Wolfe’s very interesting paper from 1992 here.

In this study many of the worlds leading experts in trigger points gathered together to attempt to demonstrate the reliability in locating trigger points in three groups of subjects and failed spectacularly. The first group they palpated for trigger points where those already diagnosed as having trigger points by other experts, another group was those diagnosed with Fibromyalgia so had muscle pains but no knots allegedly, and finally they poked a healthy control group who were both muscle knot and pain-free. Of course the examiners were blinded and had no idea who was in which group. 

These experts had as long as they liked to press and poke the subjects, butwere not allowed to question them. The subjects were all instructed to not to give the examiner any feedback or signs of pain as best as they could as they were poked. The examiners just simply had to identify those with the trigger points from those tht just had pain or had neither.

So how did they do?

Terribly, in fact really terribly. These ‘experts’ were only able to identify 18% of the subjects with so called muscle knots. In fact they incorrectly ‘found’ muscle knots in the healthy control group more than twice as much!

This study was an huge disaster for the muscle knot proponents, as it directly questions the reliability and validity of trigger points as a diagnosis. If the worlds leading experts can’t find them, what chance do the rest of us have? This paper howeverwas almost not published at all 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.

However, since Wolfes paper there has been more and more research demonstrating that we just cannot reliably find these damn muscle knots. For example this paper here by Hsieh shows that even after training from an expert, chiropractic students still cannot find muscle knots in the trunk or lower limbs that the expert found. Next a systematic review by Myburgh in 2008 here and a similar review by Lucas in 2009 here also 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 recent systematic review and meta analysis by Kietrys in 2013 here. They looked at the effectiveness of Dry Needling for Trigger Points in the Upper Trapezius. Now although the conclusions look very promising and validating for trigger points and the dry needling technique, 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

Awkward

So an awkward question we have to ask those that think these soft tissue sore spots are muscle knots is why in the last 40+ years hasn’t there been one good, robust, well designed study that can show them or demonstrate that we can find them?

Well in my opinion the simplest and most logical answer to these questions would be that these soft tissue sore spots are NOT muscle knots!

So thats my critical look at trigger points. As I have tried to show there are alternative explanations for soft tissue sore spots, but it must be acknowledged that these alternative theory’s of sub cutaneous peripheral nerve issues are just that, theory’s, also without any robust evidence.

In summary, there are some difficult and awkward questions for those who subscribe to the muscle knot explanations and treat them as such! Such as why can’t the evidence find them, and if you can’t find them, how can you treat them. Also how does poking a trigger point with a needle that will cause more micro trauma help an already so called traumatised muscle. And even more perplexing, is how can a trigger point be treated both with a method that is believed to cause an INCREASE in blood flow such as dry needling, but then conversely can also be treated by a method such as ischemic pressure applied with fingers, knuckles or elbows that is beleived to DECREASE blood flow..

This is circular reasoning and its best and worst and makes no sense to me, just like the whole trigger point bull shit brigade! 

As always thanks for reading

Keep questioning

Adam

PS: I’m sure you are probably thinking if muscle knots don’t exsist how do I explain the many many more therapists that can feel and find them? Well that in my opinion is down to the good old illusion of palpation paredolia which I have discussed here.

12 thoughts on “Soft Tissue Sore Spots of an Unknown Origin!

  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!

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