The Theory of Muscle Knots in Soft Tissue Sore Spots

Muscle Knots in Soft Tissue Sore  Spots

The concept that knots in muscle tissue contribute to pain first gained prominence in the early ’80s. The idea was brought into the spotlight by the prestigious Dr. Janet Travell, who previously served as president John F. Kennedy’s personal doctor. In collaboration with Dr. David Simons, she developed the first acupressure guides to hit the market. Soon after these books were released, the concept of knotted muscles started to become accepted by numerous medical providers, in spite of the fact that no peer assessments had been performed to test this theory. The fact is that even today, there is still no concrete proof that muscle tissue knots cause pain, or that they exist in the first place.

What Causes Soft Tissue Sore Spots?

Aside from the myofascial trigger point theory, another possibility that exists in relation to the causes of soft tissue sore spots is that they’re a result of problems with the body’s subcutaneous peripheral nerve system, a concept first suggested by respected rheumatologist John Quintner in 1994.

What causes these painful nerves are still unknown, but like muscular knots, it’s theorized that they may develop in response to either an acute trauma or minor traumas from chronic poor posture or prolonged muscle tension. These traumas may affect the nerve itself, but more often they cause symptoms by impacting the nerve’s blood supply.

Pain and the Central Nervous System

It’s worth noting that the human neurological system (which includes the subcutaneous neurological system) needs plenty of high-quality fuel to keep it working at its peak. As a result, it requires an abundant vascular supply to properly nourish it. This means that a reduced blood supply can quickly cause damage to the nerve, which is interpreted as a dangerous situation by the CNS (central nervous system) and results in increased pain signals as part of the body’s natural effort to draw our conscious attention to the threat.

It’s also a fact that the body’s nerves have access to their own neural supply center known as the nervi nevorum. So nerves are perfectly capable of producing pain signals, much like anybody tissues do, a fact which has been pointed out by rheumatologist Geoffrey Bove, who is also skeptical of the existence of knots in muscle tissue.

This theory that soft tissue sore spots can be caused by the tissue itself rather than as a result of knotted muscles seems to present a much simpler explanation for the etiology of soft tissue soreness. Furthermore, it offers a possible reason for why these knots, adhesions, and/or trigger points have never been objectively proven.

Other Studies and Reviews

Aside from Dr. David Simons, a number of the world’s top medical specialists claim they have unsuccessfully tried to locate muscle fiber knots and myofascial points in the body. One such professional is Dr. Fred Wolfe, who conducted a study in the early ’90s to determine if prominent myofascial experts could reliably and objectively locate knots or myofascial points in three clusters of study participants.

The first cluster included subjects who had been diagnosed as suffering from hyper-irritable pressure points by other specialists; the second cluster subjects were previously determined to have fibromyalgia, so having muscle pains but no knots; and the third cluster or “control group” was composed of healthy individuals who had no pathology of muscle or soft tissue pain.

The specialists were able to take as much time as they needed to diagnose the subjects using acupressure techniques, but they were unaware of the participants’ medical histories and couldn’t ask any questions about them. In addition, the study participants were directed not to provide the examining specialists any type of feedback and to try to suppress their pain responses. The experts could only establish which subjects they believed had myofascial knots based solely on palpation.

The results were not very promising with respect to proving the existence of knots, as the specialists could only determine that 18% of the participants had such points. They also inaccurately identified muscular knots as existing in the control group over two times as frequently.

The results of the experiment caused many physicians to question how valid the concept of trigger points was, particularly with regard to them being the origin of soft tissue pain. The study was nearly completely suppressed as a result of major conflicts between Dr. Wolfe and the co-authors after accusations that the results had been unfairly manipulated. Even so, there have been additional studies performed after Dr. Wolfe’s experiment that indicate myofascial points and knots don’t really exist.

Another study performed by Yueh-Ling Hsieh demonstrates that despite receiving specialized training, chiropractors are still unable to locate knots in the body’s back or extremities. Other reviews by Myburgh in 2008 and Lucas in 2009 have also attempted to point out the inadequate design, techniques, and prejudice in most of the studies performed on soft tissue and cast a weary eye on the usefulness and integrity of the myofascial point theory.

This lack of quality research on muscle knots and trigger points is also brought to light in a 2013 critique by Kietrys.

Problems With the Logic Behind Muscle Tissue Knots

The boldest question that can be asked of specialists who contend that soft tissue sore spots are caused by knots or irritated pressure points is: How come no well-developed study performed during the last half-century has been able to conclusively show or prove that they actually exist? Perhaps the easiest and most rational answer to this important question is that these painful spots simply are not the results of any so-called “muscle knots” lurking throughout the body.

As mentioned previously, a number of other possible causes of soft tissue soreness exist. However, it must be taken into account that these other ideas regarding peripheral nerve problems are still just theories and have no supporting evidence to back them up.

To sum up, these are important concerns that anyone who believes in the concept of muscle knots should take into consideration. After all, if there’s no medical evidence that they exist, how can they possibly be found and treated?

From a logical standpoint, there’s the problem of how pressing soft tissue sore spots with a finger or needle – which is thought to produce micro-traumas in the tissue being treated – can provide therapy to a muscle or tissue that’s already been traumatized. On the same note, how is it possible to treat a muscle tissue knot with a technique that’s thought to induce more tissue bleeding (like acupuncture), and why would applying pressure with a knuckle or acupressure tool cause the muscle to relax instead of tense up against the contraction? This type of logic seems contradictory and needs to be carefully re-evaluated by anyone who suffers with soft tissue sore spots.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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