Practical Science on Movement and Pain

“Can You Feel that Knot?” Not!

I get this question all the time in my practice as Rolfer. It usually prompts me to start trying to correct some misconceptions. Here’s why.

1. Thinking about knots might increase threat

First and foremost, there is good reason to believe that the way we think about the state of our body can affect our sensations and pain levels. For worse or better.

As I’ve discussed before, pain is an output of the brain that can be modified by cognitive inputs. Before the brain decides how much pain to create in response to some perceived danger in the tissues, it will try to answer the question “how dangerous is this really?”

To do that, it will consider all the information relating to the condition of the tissue, including nociception, proprioception, and cognitive information such as memories, emotions, diagnoses, and mental images of the tissue. If you are constantly telling yourself that your muscles are tied into knots, this is one of the inputs into the system, and it doesn’t sound like good news.

Of course we know consciously that the muscles aren’t literally tied in a knot (actually I think some of my clients actually believe there is literally a knot.) But the parts of the brain that evaluate threat might not be quite so sophisticated as to understand the difference between metaphor and reality. And a picture is worth a thousand words. This is why many movement practices such as yoga, martial arts, and tai chi employ imagery as way to modulate muscle function.

And believe me, none of them ask you to imagine your muscles are tied in knots.

If you are constantly thinking of a knot whenever you sense the tightness in a particular muscle, you are probably increasing the chance that you will feel some unpleasantness associated with the tightness. So I ask my clients to consider this and conceive of their muscle tightness in less threatening terms. For example, how about just this:  that area feels tight.

Oh, and that doesn’t mean the area actually is tight.

2. Most “knots” aren’t even tight!

Another problem I have with the “knot” idea is that the supposed knot is often no tighter than surrounding tissue.

Part of the reason for this is that the subjective feeling of tightness in a muscle is not the same as actual mechanical tension in the muscle. So you can have a feeling of tightness in areas that are actually pretty loose, and a feeling of looseness in areas that are mechanically tense.

For example, in this study it was found that the most painful trigger points in the upper traps (an area that is always described as being tight) were actually less mechanically tight (as measured by an algometer) than surrounding areas.

So just as pain is not an accurate measure of tissue damage, the feeling of unpleasant tightness is not a measure of actual mechanical tension. (Whether excess mechanical tension is a common cause of pain, or whether trigger points exist are separate issues that I won’t get into here!)

3. Most knots are actually bones

This happens ALL the time. Ninety percent of the time when a client starts feeling around in their sore tissues and finds what they think is a knot, what they have actually found is a bone. So of course it feels hard, and of course it hurts to press on it.

For example, that knot in the upper traps? That’s often the superior tip of the scapula. The hard areas in between the scapulae are usually ribs. And that dense spot in the low back is often the transverse process of a lumbar vertebrae.

Although many clients are sometimes a little resistant to this idea, many are relieved to learn that their anatomy is not deformed in some pathological way. And several have told me that they are glad they don’t need to keep pressing on the knot – with foam rollers, lacrosse balls, or whatever other implements they can find – to “release” it.

Conclusion

Language matters. It affects threat and it directs treatment decisions. So share this post with someone who thinks they have a muscle knot!

And if you can think of any other language related thought viruses that can make us sick and send us down the wrong path, let me know know in the comment section.

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19 Responses to “Can You Feel that Knot?” Not!

  1. Mr Hargrove, another interesting post! I also like the change in look for the site. Do you understand muscle hardness to be the same as tightness? I suppose both are measuring deformation. Also, I was wondering if you had any thoughts on how much pressure one should be able to exert on a given structure to determine whether or not dysfunction is present. An example would be tenderness across the front of the tibia in the case of anterior tibialis strain (shin splints). I have found that once the tissue over the bone itself has been treated manually, the pain threshold is greatly increased in that area as well as over the muscle. My understanding that a moderate amount of pressure (about 4kg or so)should not elicit a pain response in “healthy tissue” (I know we could debate about that definition for hours)- the exceptions being over sense organs, genitals and mucous membranes. Is tenderness even over a rib to be expected?

    • Todd Hargrove says:

      Hi George,

      Thanks for kind words. Those are all great questions, but I’m afraid I don’t have any good answers. I usually don’t really have a good idea of why some tissue is sore, probably because its very hard to know, and my treatment method will probably be pretty similar regardless – slow, gentle, non threatening, novel sensory input, education, exploration of movement options, etc.

  2. Dave Nolan says:

    Dr Morris, some great questions. In your example of anterior tibialis strain, how do you treat the “tissue” over the bone, and by what mechanism do you think the pain threshold has declined?

    • Dr George Morris says:

      I’m sorry it’s taken me so long to reply. Depending on the severity of the strain I tend to bring the patient through a full range of motion to assess any limitations and to note the tissue restrictions in the sliding surfaces and any specific directions that cause pain. I use a form of pin and stretch (tack and stretch, ART) etc while bring the patient through a full ankle range of motion in a non-weight bearing position, and then working up to weight bearing. My guess as to why the pain threshold declines is multi-factorial (isn’t everything these days?). I suppose I’m increasing tolerance as a result of accommodation and raising the threshold, I’m assuming there is some endorphin release (most of my treatments for this condition are mildly uncomfortable at first) and depending on my findings, I tend to manipulate the joints above and below which can provide some local analgesia. As a note, I tend to start with the tissues near the bone but not directly over. My guess is that there is a reduction in tension of the overlying connective tissues – at least there is much more slack and the tissue is able to slide over the surface of the bone more easily after treatment.

      Further down the line a reduction in inflammation can be expected which also contributes to reducing the pain. I find that all of this is for naught without proper hydration and biomechanics (positioning, muscle activation, motor control etc).

  3. Frank says:

    I think the singular of vertebrae is vertebra. Just sayin.

    • Todd Hargrove says:

      I think a lot of the time when people say “just sayin”, what they really mean is “just being a dick.” Just sayin.:)

  4. Brad Jones says:

    Great article Com. Todd! I noticed you used the term “trigger point,” I’m curious to know how you define a trigger point?

    • Todd Hargrove says:

      Hi Com. Brad,

      The trigger point issue is a whole can of worms that I don’t understand well enough to have a strong opinion on. And the definition is part of it. If you define trigger point as just a sore spot, then fine, everyone has trigger points. If you define it as a sore sport caused by a taut band which involves an involuntary contraction and an energy crisis which causes chemical changes and nociceptive signaling and then some referred pain, then that’s a different thing. And whether they are common and can be treated by pressing on them or needling them or stretching them is a separate question. I don’t know! What do you think?

      • Brad says:

        Darn! I was hoping that you had come up with a nice, consice definition:). I don’t know either. People love to use the term “trigger point,” the problem is in the definition. I try to steer people toward a definition that has much more to do with the ectoderm than the mesoderm .

      • Hi Todd,

        I’ve experienced a “knot”, a tight, tender spot in the soft tissue around the upper medial angle of the shoulder blade that could not be relieved by massage and ultrasound applied by a physical therapist. No type of hands-on could soften that knot. However it was completely eliminated by strengthening intrascapular muscles and improving upper body posture. Rene Cailliet in his book “Neck and Arm Pain, ed.3, 1991″ discusses scapulocostal syndrome where the scapular attachment site of the levator scapula becomes inflamed and knot-like due to traction on the muscle. In slouched upper body posture with the shoulder blades “drifting” apart and away from the spine, the levator scapula is stretched but at the same time bears the brunt of anchoring the shoulder blades to the spine (unfortunately the more delicate cervical spine); while anchoring to the lower, more robust thoracic spine has been weakened by elongation/weakening of rhomboids, and middle and lower trapezius.

        That was the only actual “knot” I’ve ever experienced in spite of my many years of neck and upper back pain (due to poor upper body posture). However, I had plenty of sore, tight muscles such as the back and sides of my neck and upper shoulder/trapezius area due to “forward head” and slouched, kephotic posture.

        I have talked to some who claim to have trigger spots all over body areas like chest, back of neck, and upper trapezius (that would be tight in poor upper body posture). One claims that he can’t assume better posture because of tightness of those chest muscles (he worked these out excessively) and that dry needling helps relax them so that he can improve his posture by strengthening upper back muscles.

        By the way I’m a fan of your posts and subscribe to them of course

        Rochelle

  5. Rajam Roose says:

    Hi Todd,
    What a great article! As a massage therapist, I’ve always thought that promoting the idea of “knots” actually made clients feel worse. When people come into my office for a massage and tell me how previous therapists told them their back was “full of knots” or that their shoulders “are like bricks”, I would tell them the opposite and try to change them from that line of thinking. Often, the look of relief on their faces was quite obvious when they heard that their back isn’t “full of knots.”

    Another example is when they come in and using the opposite hand to pop over the opposite side levator/trap section on top of the scapula and tell me how they always have these “big knots”. I will explain that those are just two muscles running different directions and that is not a “knot” and is just a part of the body that will always be there. Same with the quadriceps, as they feel me going over the different muscles and think those are “knots”.

    I’m going to share this on my FB business page for my clients to read.

    Thanks for another great article!

    Warmly,
    Rajam

    • Todd Hargrove says:

      Hi Rajam,

      Exactly! I have noticed the same thing about those overlapping/snapping muscles. Clients often think that is some form of pathology. I have to admit, many will be unconvinced and a little upset that I don’t share their diagnosis. You have to be careful and approach this the right way!

  6. Jeewon Kim says:

    Hi Todd, another thought provoking article! I really like your series on pain, but I must confess the more I ‘look into it’ the more questions I have.

    Like Dr. Morris I’m not sure what muscle ‘tightness’ and ‘hardness’ really mean. Until now I had thought those terms were simply colloquial, whether used by a therapist as a tactile description, or by a patient as a subjective sensation.

    From a casual google search:

    “Algometry consists of a pressure instrument known as an algometer, which has a one centimeter rubber-tipped stylus and a force dial which reads in pounds or kilograms. This device measures sensations of pain due to pressure. Kilograms were used in this study. Pain threshold is determined by the amount of force/cm2 required for a person to first perceive pain. This reading is then recorded. Source: Webster’s Revised Unabridged Dictionary @ 1996, 1998 MICRA, Inc.” (http://www.learniet.com/case_study.htm)

    hardness = pain threshold due to pressure as measured by an algometer; the higher the pressure/cm, the harder the spot and vice-versa

    So the researchers weren’t measuring ‘mechanical tightness’ but rather perceived pain from pressure applied by a machine. The question which remains unanswered for me is, what is ‘actual mechanical tension’? Also, the perception of pain due to pressure on bone seems to vary quite a lot. So the question remains, why do some spots, those ‘knots’ which are actually bone, hurt so much more than other spots on bone?

    Cheers,
    JK

  7. Becky says:

    Todd – Just a few thoughts on muscle “knots” and the effects of language. I’ve had leg and back pain for years now, the original trigger being a knee injury. One of the worst symptoms was severe soreness/tenderness in the IT band area of both thighs. If I poked this area with a finger, the sensation was so horrible I would feel nauseous.
    A massage therapist told me that I had extensive muscle knots and scar tissue in my IT bands, and this idea was really persistent, and negative for me – I thought I had caused some major structural damage to my legs. It really made me lose confidence in my body, and my body’s ability to heal.
    A few months ago, after reading some material on your website, I decided to completely stop doing stretching exercises, as an experiment. Within a few weeks, the pain and tenderness had gone, which I found quite amazing.
    I think these things that some therapists may say, quite flippantly, can become obsessional for the client, and these obsessions and anxieties then stand in the way of awareness and healing.

  8. Excellent post. The results seem amazing. Agree that it can get into someone’s head though.

  9. Lauren Wilder says:

    I’ve had muscle stiffness and cramps my entire life. I’ve done the muscle biopsy testing etc thing (odd results, but nothing conclusive.) My husband has noted for a long time that I have distinct muscular lumps, everywhere actually. He calls them knots. I much prefer knots to lumps. They’re very painful to the touch, otherwise i dont notice them, but I do notice and can’t escape the stiffness. Massage eventually gets rid of them, but they spring right back up. Rolfer? Like my husband goes to? I’d have to be anesthestized. But sometimes, knots really are knots.

  10. Eina says:

    My neck, back, hips and knees are pretty scarred from idiot parents who kept forcing me in basketball, soccer and volleyball with dangerous coaches as I rapidly went from 5’2″ at 14 to 6′ at 16, then 6’3″ at almost 18. Major abuse to the muscles and joints who didn’t get proper care during rapid development. Including doing the typical girl knee damage to my ACL, which was ignored despite major swelling until a few weeks prior to turning 18, I took every part – all ligaments, completely severed quad tendon, damage to other tendons – out in my left knee and most – all ligaments, torn quad tendon – of my right knee.

    I do get inflammatory reactions on “typical” trigger points, which will tighten up enough to see the swelling lumps even under a shirt. But, take Advil, take an ice bath, then a hot shower, apply topical arnica with pressure over the lumps, they will go down. They’re always there, but usually not annoying. Perhaps oddly, a softer mattress helps, I suspect it allows better spread of support vs a few points. Add in, no pillow under my head, but one under my crappy hips and two under my annoyed knees helps.

    But – and why I’m writing – I have to believe I’m an extreme case. I’m far from typical, most people aren’t stretching overly stretched, growing muscles to the extent I had. There’s a clear difference between a sore muscle and knots.

    But, the biggest issue? Dehydration. My body riots if I’m dehydrated. I drink very limited caffeine, live on actual coconut water, homemade juices and water. Running on caffeined simple syrup and alcohol has got to make dehydration worse, thus, muscle pain.

    • Todd Hargrove says:

      Thanks for sharing your story Eina, and sorry to hear about the pain. I think you are right that your case is unusual. Best of luck in finding some relief.

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