As practitioners we are continually dealing with dysfunctional musculoskeletal systems. Typically dysfunction develops and is perpetuated... Read Article
Muscle knot basics: what they are, what they do, and how to treat them
Muscle knots are those tender lumps in your muscles therapists find. They are arguably the biggest cause of musculoskeletal pain such as back, neck and shoulder pain, yet are so often either not diagnosed or poorly treated so they progress to become chronic debilitating pain syndromes, including fibromyalgia. To help avoid that, in this article we’ll show:
What are muscle knots
Muscle knots are tender lumps with your muscles that shoot pain when pressed upon. They are parts of your muscle that have gone into spasm or “cramped” forming the lump. As we’ll discuss in the section on what muscle knots do, these spasms “lock on" and continue to grow causing a host of adverse effects including often eventual pain.
The technical name
There are no actual knots in the muscles. They just feel like knots. The technical name for muscle knots is (myofascial) trigger points.
Symptoms of muscle knots
Muscular pain, fatigue and reduced performance
Muscle knots can cause muscular pain, plus as we will see later will affect the way your muscles works. Symptoms may be deep muscular pain, reduced performance and easy fatigue. Symptoms will often increase with activity.
Muscle knots cause muscles to abnormally tighten, reducing flexibility. It is important to note that this tightness can make muscles easy to tear, or cause problems where they attach (such as tennis elbow ).
Muscle knots often refer pain away from the actual problem. This example shows the common problem of muscle knots in the upper trapezius muscles causing headaches.
Muscle knots can cause chronic pain, disturbances to sleep, plus as mentioned above cause muscles to easily fatigue. These can contribute to a variety of issues ranging from being tired and run down through to psychological and emotional problems.
How muscle knots are diagnosed
A trained therapist will find muscle knots in a matter of seconds, however they do not show up on any laboratory tests or medical imaging. Diagnosis is by examining the muscles and finding:
- a tight band within the muscle
- a tender lump which shoots pain when pressed upon
- (sometimes) a “jump sign” which is the muscle twitching when the muscle knot is pressed upon.
What causes muscle knots
There are a variety of possible causes of muscle knots including blood chemistry issues and emotional stress, however, these are the big ones.
Reduced blood supply
We’ll see later that a big part of muscle knots is a lack of nutrients and a build up of waste products due to reduced blood flow. The main causes of reduced blood flow are:
- Postures where muscles are tight (pressing on blood vessels), and movement reduced. An example would be sitting at a desk.
- Muscle knots tighten muscles themselves (again pressing on blood vessels), worsening the problem. This is one reason why muscle knots continue to grow.
Examples include repeated use of forearm muscles by some trades people or production line workers.
Includes repeated strains and injuries due to sport or manual labour.
How common are muscle knots
If you have pain
If you have musculoskeletal pain such as back neck or shoulder pain studies show that you are almost guaranteed to have muscle knots.
Example: neck and shoulders
In an investigation of workers with pain in their neck and shoulder region the workers were checked for muscle knots in their neck, shoulder and arm muscles (1). The results were:
- Blue collar workers: Ave. 16 muscle knots
- White collar workers: Ave. 17 muscle knots
If you have no pain
But what if you have no pain? An investigation of pain free adults found that nearly 90% had muscle knots in their shoulder muscles alone (2).
What muscle knots do: pain and other effects
We’ve seen that muscle knots are a tender lump within the muscle that keeps growing over time. Scientists found that what they are is actually a combination of muscle spasm, muscle tightness and a build up of wastes (3–8). As shown below these feed on each other creating what is known as a positive feedback loop.
The positive feedback loop
- spasm causes muscles to tight
- tight muscles press on blood vessels restricting blood flow
- restricted blood flow causes a build up of waste products
- the build up of wastes becomes toxic, causing spasm (and around again in circles)
The problems this causes
Now you know what’s happening inside the muscle lets look at the problems this causes.
The most obvious symptom of a muscle knot is pain. Scientists have made charts like the one at the start of this article showing common trigger points (the technical name for muscle knots) and where they refer pain to.
Long before muscle knots start shooting pain spontaneously they still cause pain when pressed upon and cause a host of other problems. Lets look at these.
Tiredness, rapid fatigue and pain on exertion
Muscles containing muscle knots suffer from restricted blood flow and are already partially fatigued because of the ongoing spasm. Therefore you may suffer from:
- rapid fatigue
- pain on exertion
- as discussed in separate articles this can i) slow down reaction times for sports , and ii) cause joint movement to be less controlled resulting in pain and injuries (9–14).
Abnormal tightness: tears and attachment pain
Muscles with muscle knots are constantly tight, and because part is trying to contract all the time they will resist stretching. Because of this they are:
- prone to tearing
- the extra tension may cause the muscle attachments to become painful (eg. tennis elbow )
- they will resist stretching, or quickly re-tighten
Normal posture is maintained by the tension of the muscles. An abnormally tight muscle with a trigger point will alter this balance, causing postural changes.
Joint alignment problems
We’ve see how abnormally tight muscles due to trigger points can alter your posture. The consequence of that is that joints no longer sit in their normal neutral position. This creates uneven pressure on the joint surfaces and can result in injury or long term degeneration (abnormal wear).
Muscle knots are too often not diagnosed or poorly treated
Muscle knots not diagnosed
Despite practically everyone having them and tmuscle knots being arguably the biggest cause of most common musculoskeletal pain syndromes they do not show up in laboratory tests or medical imaging. Further, drug companies make no money from treating them. Because of this trigger (the technical name) are rarely mentioned in medical journals and doctors are instead advised to prescribe symptom relieving drugs. As examples, the following articles discuss conditions where trigger points are a huge cause but rarely mentioned in medical journals.
Muscle knots poorly treated
If muscle knots are diagnosed they are often poorly treated. The key issue is that therapies are used to (temporarily) stop muscle knots shooting pain, but not to eliminate them (15,16). They call this “deactivating” the muscle knot. This applies whether it’s a course of needles or laser, or a release technique you’ve seen on youtube. We discuss in our article Why do trigger points keep coming back .
I hope you can see the problem with this. The muscle knots are still there. They still cause all the extra problems discussed above, and of course will start hurting again as soon as they are re-aggravated. Later we’ll show you a much better way of doing things.
How muscle knots progress to chronic pain or fibromyalgia
As we have seen neither failing to diagnose trigger points and masking them with symptom relieving drugs, nor typical muscle knot therapies that just deactivate trigger points actually get rid of the muscle knots. Therefore too often muscle knots are allowed to continue to cause pain for years and often decades.
As discussed in our article on fibromyalgia , over time the continued bombarding with pain sensitises your nervous system so it becomes like a pain amplifier. When this happens normal sensations become painful and painful stimuli become much more severe. This is the basis of fibromyalgia, but can also be a major factor in a lot of other chronic (long term) pain syndromes.
Effective treatment and management of muscle knots
As mentioned above, the typical goal of muscle knot therapy is to merely deactivate the muscle knots, not get rid of it. To the uninformed the pain goes away and the problem is fixed, but of course it is still there. Please allow us to share with you an example that shows how futile a lot of courses of trigger point therapy actually are, but do show us how trigger points can actually be eliminated.
Example: trial of trigger point therapy for shoulder pain
In this trial the world’s top trigger point (the technical name for muscle knots) scientists used 12 very extensive trigger point therapy sessions to test whether trigger points caused shoulder pain (17). This produced excellent symptom relief, but as you can see by this chart after all that treatment about 2/3 of trigger points were still there.
If 12 extensive therapy sessions from the world’s best trigger point scientists could only eliminate 2/3 of trigger points neither the trigger point release you learned of YouTube or a course of half a dozen needles, laser or massage therapy sessions are going to make much of an impact.
The 12 sessions did relieve the pain and eliminate 1/3 of trigger points, so if effective treatment is continued it is likely the trigger points will continue to diminish and maybe go altogether. Because of this the basis of our effective therapy is to have an effective home therapy that you can easily and inexpensively keep repeating, to not only relieve pain but to continue working on the trigger points.
Your effective solution
We have a separate article How to treat trigger points at home that gives the complete strategy plus multiple effective self treatment options. So here we will just give a summary of the important points, plus the best home trigger point therapy option.
You may be able to do a lot of therapy yourself, but to help you get the best possible results and to stay safe we recommend that you get some professional advice.
- muscle knots are often part of a more more musculoskeletal problem they can help manage (18)
- they can help you find the muscle knots and show you how to do the therapy more effectively.
Avoid aggravating activities
You may need to at least temporarily avoid activities that aggravate the condition
Effective self therapy
We’ve seen that 12 sessions from the world’s best only partially remedied the problem, so:
- you need a lot more than 12 applications, which for most will mean a self therapy
- it will need to be very effective
The best solution
Luckily we’ve got the ideal solution: using a vibration massager. We have a lot more information about this in our article How to treat trigger points at home , but proper vibration massagers not a massage gun or percussion massager are:
- very easy to use (you just sit the machine on and let it penetrate), and
- the vibrations penetrate and do the key things required to help eliminate the trigger point’s positive feedback loop.
Getting a vibration massager
There are some good units on the market, but a lot that are not that effective. Please see our article How to choose a massager . Be especially aware that most massage guns are based on percussion massage rather than vibration. This is a gimmick that makes them a lot less effective and potentially dangerous .
We make two hand held massagers that are easy to use and give excellent therapeutic vibrations. These are our General Purpose Massager and our Ultimate Quad Head Massager . They are very effective on trigger points. We have had the General Purpose Massager for about a decade and it is widely used by professionals across Australia, New Zealand, the UK and Europe. Our newer machine the quad head has the advantage of being able to treat a larger area at one, plus can easily be used as a “chair massager” or “cushion massager.
DrGraeme massagers were originally built by Dr Graeme for use in his clinic, and to prescribe to his patients for additional self use at home. Now these are used by colleagues and other professionals for similar purposes. If you are a professional and wish to know more about this therapy, or possibly get a sample massager to trial please check out our practitioner page .
Appendix: Alternate trigger point therapies
The medics have a wide selection of medications they use to relieve the symptoms of trigger points. Of course they do nothing to eliminate the trigger points, and all the non-pain effects will still be there.
- nonsteroidal anti-inflammatory drugs (NSAIDs)
- muscle relaxants
- tricyclic antidepressants
- botox injections
Alternative professional therapies
Our article What is the best treatment for trigger points discusses the research backing for the professional therapies below. As mentioned above though all made the goal of pain relief rather than elimination. In the trials they often did 5-10 therapy sessions, which is a large expense and inconvenience for what amounts to temporary pain relief.
- Dry needling
- Manual trigger point therapies
- Fernández-De-Las-Peñas C, Gröbli C, Ortega-Santiago R, Fischer CS, Boesch D, Froidevaux P, et al. Referred pain from myofascial trigger points in head, neck, shoulder, and arm muscles reproduces pain symptoms in blue-collar (Manual) and white-collar (Office) workers. Clin J Pain. 2012;28(6):511–8.
- Lucas KR, Rich PA, Polus BI. How common are latent myofascial trigger points in the scapular positioning muscles? J Musculoskelet Pain. 2008;16(4):279–86.
- Simons DG. Understanding effective treatments of myofascial trigger points. J Bodyw Mov Ther. 2002;6(2):81–8.
- Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain Headache Rep. 2012;16(5):439–44.
- Dommerholt J, Bron C, Franssen J. Myofascial Trigger Points: An Evidence-Informed Review. J Man Manip Ther. 2006;14(4):203–21.
- Jafri MS. Mechanisms of Myofascial Pain. Int Sch Res Not. 2014;2014:1–16.
- Zhuang XQ, Tan SS, Huang QM. Understanding of myofascial trigger points. Chin Med J (Engl). 2014;127(24):4271–7.
- Shah J et al. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. HHS Public Access. 2015;7(7):746–61.
- Lucas KR, Rich PA, Polus BI. The Effects of Latent Myofascial Trigger Points on Muscle Activation Patterns During Scapular Plane Elevation. Jclb. 2007;25(8):765–70.
- Phadke V, Ludewig PM. Study of the scapular muscle latency and deactivation time in people with and without shoulder impingement. J Electromyogr Kinesiol. 2013;23(2):469–75.
- Bohlooli N, Ahmadi A, Maroufi N, Sarrafzadeh J, Jaberzadeh S. Differential activation of scapular muscles, during arm elevation, with and without trigger points. J Bodyw Mov Ther . 2016;20(1):26–34. Available
- De Mey K, Danneels L, Cagnie B, Cools AM. Scapular muscle rehabilitation exercises in overhead athletes with impingement symptoms: Effect of a 6-week training program on muscle recruitment and functional outcome. Am J Sports Med. 2012;40(8):1906–15.
- Worsley P et. al. Motor control retraining exercises for shoulder impingement: effects on function, muscle activation and biomechanics in young adults. J Shoulder Elb Surg. 2013;22(4):e11–9.
- Moraes GFS, Faria CDCM, Teixeira-Salmela LF. Scapular muscle recruitment patterns and isokinetic strength ratios of the shoulder rotator muscles in individuals with and without impingement syndrome. J Shoulder Elb Surg. 2008;17(1 SUPPL.):48–53.
- Uemoto L, Garcia MAC, Gouvêa CVD, Vilella O V., Alfaya TA. Laser therapy and needling in myofascial trigger point deactivation. J Oral Sci. 2013;55(2):175–81.
- De Las Peñas CF, Sohrbeck Campo M, Fernández Carnero J, Miangolarra Page JC. Manual therapies in myofascial trigger point treatment: A systematic review. J Bodyw Mov Ther. 2005;9(1):27–34.
- Bron C, De Gast A, Dommerholt J, Stegenga B, Wensing M, Oostendorp RAB. Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial. BMC Med. 2011;9.
- Denneny, Diarmuid et al. Trigger point manual therapy for the treatment of chronic noncancer pain in adults: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2019;100(3):562–77.
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About Dr Graeme
Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more