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Editorial

Soft tissue sore spots of an unknown

origin
Adam Meakins
Trigger points are common clinical diagnoses in the musculoskeletal profession.
However, questions have been raised about
what they are and how they are treated.1
Trigger points were rst described by Travell
and Simons as tender, painful areas found in
myofascial tissue when palpated. These are
often described as muscle knots or taut
bands, and are considered to be areas of
adverse sustained muscular contraction
caused either from direct trauma to myofascial tissue or through repeated microtrauma
from postural or activity-related stresses/
strains. This is believed to cause a crisis at
the motor end plates, creating a sustained
adverse muscular contraction that is then felt
as pain either locally or referred elsewhere.
However, despite widespread acceptance
of this theory, and a large and diverse
industry built around the treatment of
trigger points, including various deep tissue
massage and acupressure techniques and
more recently, the growing popularity of
dry needling, the theory of adverse muscle
knots and taut bands as a cause of soft tissue
pain has never been adequately explained.

SO WHAT ARE THEY?

More and more clinicians question the
accepted explanations for trigger points in
the light of growing research and understanding in neurophysiology and pain
science. It is questionable if trigger points
are adverse areas of sustained contraction
in muscles for a number of reasons and
alternative causes of trigger points, such
as peripheral neural inammation or
ischaemic tissues, may be more likely.2
The acceptance of knots in muscles never
sat well with me. As a young physiotherapist, I regularly infuriated my educators as
they attempted to teach me how to palpate
trigger points, but despite provoking pain I
could never feel anything adverse. Perhaps
it was my lack of skill or experience in palpation; however, over a decade later, I can
still condently say that I have never felt a
true trigger point.
When I discuss this with other therapists
it seems that I am in a minority. Nearly all
other therapists I speak to tell me that they
have felt adverse knots from time to time,
and they tell me I simply need more
Correspondence to Dr Adam Meakins, Department
of Physiotherapy, Spire Bushey Hospital, Heathbourne
Road, Bushey, Herts WD23 1RD, UK;
adammeakins@hotmail.com
348

training. Maybe they are right; maybe I just

have sausage ngers that cannot palpate anything. However, there is evidence that even
the worlds leading experts are also unable
to accurately or reliably locate trigger
points.3 If these experts cannot nd them,
then what chance do the rest of us have?

SO WHAT ABOUT THE EVIDENCE?

Studies have tried to visualise trigger points
using MR elastography, sonoelastography or
Doppler ultrasound. However, these studies
are of poor quality, lacking in control groups
or descriptions of how they classied, diagnosed or located the trigger points.4
Tissue biochemistry research has been
conducted around trigger points, and elevated levels of inammatory and neurotransmitter chemicals have indeed been
found.5 However, control tissue samples
were similar.
Electromyography (EMG) studies have
reported adverse electrical activity in and
around trigger points.6 These very small elevated EMG spikes, however, cannot be reliably distinguished from background latent
noise or artefacts from the ne, wire needles.
Dry needling for treatment of trigger
points has scant evidence; studies have poor
methods and high risk of bias. The proposed
mechanism for dry needling is the needle
point disrupts the motor end plate crisis by
stimulating the neural tissue. However,
demonstrated trigger points have not been
shown to be adverse muscle contractions
caused by motor end plates in crisis. So this
explanation is highly questionable.
The temporary pain reducing effects
often seen with painful treatments, such as
dry needling, can be attributed to other
well-known neurophysiological processes,
such as diffuse noxious inhibitory control,
and other non-specic psychological
effects, for example, the patients expectations and placebo effects.7 It is also worth
remembering that pain is a complex phenomenon. Just because pain is palpated at a
location does not mean that this location is
the source of pain, and when a treatment is
delivered to a structure and it relieves pain,
this still does not mean this structure was
the source of pain.

stimulus that is perceived as something clear

and distinct. For example, a therapists belief
or expectation that they will nd a trigger
point can and does cause them to palpate
perfectly normal anatomy and interpret it as
an abnormal trigger point. Pareidolia is actually a common phenomenon throughout the
musculoskeletal professions and occurs due
to multiple factors, such as past experiences,
personal preferences and preconceptions.8
In summary, alternate theories of what
trigger points are do exist. They explain
why we often see patients with soft tissue
pain that is painful on palpation, but not
why we cannot reliably or accurately feel
knots or taut bands. However, it must be
recognised that these alternative theories
also lack any robust evidence and many
questions remain still unanswered. In light
of this uncertainty, I suggest that we should
not be explaining trigger points as muscle
knots, but rather that they are simply soft
tissue sore spots of an unknown origin!
Twitter Follow Adam Meakins at @adammeakins
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned;
externally peer reviewed.

To cite Meakins A. Br J Sports Med 2015;49:348.

Accepted 28 January 2015
Br J Sports Med 2015;49:348.
doi:10.1136/bjsports-2014-094502

REFERENCES
1

SO WHAT ARE WE PALPATING THEN?

The phenomenon of pareidolia
believe, explain what therapists are
when they palpate for trigger
Pareidolia is dened as vague and

can, I
feeling
points.
obscure

Meakins A. Br J Sports Med March 2015 Vol 49 No 6

Quintner JL, Bove GM, Cohen ML. A critical evaluation

of the trigger point phenomenon. Rheumatology
2014:pii: keu471. Published Online First.
Quintner JL, Cohen ML. Referred pain of peripheral
nerve origin: an alternative to the myofascial pain
construct. Clin J Pain 1994;10:24351.
Wolfe F, Simons DG, Fricton J, et al. The bromyalgia
and myofascial pain syndromes: a preliminary study of
tender points and trigger points in persons with
bromyalgia, myofascial pain syndrome and no
disease. J Rheumatol 1992;19:94451.
Chen Q, Bensamoun S, Basford JR, et al. Identication
and quantication of myofascial taut bands with
magnetic resonance elastography. Arch Phys Med
Rehabil 2007;88:165861.
Shah J, Danoff J, Desai M, et al. Biochemicals
associated with pain and inammation are elevated in
sites near to and remote from active myofascial trigger
points. Arch Phys Med Rehabil 2008;89:1623.
Simons DG, Hong CZ, Simons LS. Endplate potentials
are common to midber myofacial trigger points. Am J
Phys Med Rehabil 2002;81:21222.
Sprenger C, Bingel U, Bchel C. Treating pain with
pain: supraspinal mechanisms of endogenous
analgesia elicited by heterotopic noxious conditioning
stimulation. Pain 2011;152:42839.
Foye P, Abdelshahed D, Patel S. Musculoskeletal
pareidolia in medical education. Clin Teach
2014;11:2513.

Downloaded from http://bjsm.bmj.com/ on November 30, 2015 - Published by group.bmj.com

Soft tissue sore spots of an unknown origin

Adam Meakins
Br J Sports Med 2015 49: 348

doi: 10.1136/bjsports-2014-094502
Updated information and services can be found at:
http://bjsm.bmj.com/content/49/6/348

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PostScript
To cite Elliott A, La Gerche A. Br J Sports Med
2015;49:10251026.
Accepted 20 January 2014
Published Online First 19 December 2014

http://dx.doi.org/10.1136/bjsports-2014-094363
Br J Sports Med 2015;49:10251026.
doi:10.1136/bjsports-2014-094441

REFERENCES
1

Leischik R. Myths of exercise induced right ventricular

injury: the bright side of the moon. Br J Sports Med
2015;49:636.
Teske AJ, Prakken NH, De Boeck BW, et al.
Echocardiographic tissue deformation imaging of right
ventricular systolic function in endurance athletes.
Eur Heart J 2009;30:96977.
La Gerche A, Heidbuchel H. Can intensive exercise
harm the heart? You can get too much of a good
thing. Circulation 2014;130:9921002.
Heidbuchel H, Hoogsteen J, Fagard R, et al. High
prevalence of right ventricular involvement in
endurance athletes with ventricular arrhythmias. Role
of an electrophysiologic study in risk stratication.
Eur Heart J 2003;24:147380.
Benito B, Gay-Jordi G, Serrano-Mollar A, et al.
Cardiac arrhythmogenic remodeling in a rat model of
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Professional football clubs

could deliver pragmatic
physical activity interventions
to promote mental health
Rosenbaum et al1 provide evidence of the
importance and potential benets of using
physical activity interventions for the treatment of mental illness. The authors highlighted the need for pragmatic physical
activity interventions. This letter introduces
the role of professional football clubs.
Professional football clubs have delivered
a variety of community-based interventions.
Clubs programmes have engaged hardto-reach populations across the lifespan,2
supported clinically signicant weight

1026

reduction through cost-effective interventions.3 This approach offers potential for

delivering benets for health and social
well-being4 for participants with a mental
illness.5
As the nancial cost of mental illness is
substantial, we concur with Rosenbaum
et al1 that it is vital to consider pragmatic
and novel approaches for promoting
physical activity. Professional football
clubs community interventions add a
further opportunity for policymakers,
commissioners and applied practitioners
to translate existing evidence to tackle
mental illness.
Daniel Parnell, Kathryn Curran
Leeds Beckett University, Centre of Active Lifestyles,
Leeds, UK
Correspondence to Dr Daniel Parnell, Leeds Beckett
University, Centre of Active Lifestyles, Headingley
Campus, Carnegie Faculty, Leeds L36 3QS, UK;
d.parnell@leedsbeckett.ac.uk

Premier League football clubs (FFIT): a pragmatic

randomised controlled trial. Lancet 2014;383:
121121.
Henderson C, OHara S, Thornicroft G, et al. Corporate
social responsibility and mental health: the Premier
League football Imagine Your Goals programme. Int
Rev Psychiatry 2014;26:4606.
Pringle A, Zwolinsky S, McKenna J, et al. Health
improvement for men and hard-to-engage-men
delivered in English Premier League football clubs.
Health Educ Res 2014;29:50320.

CORRECTIONS
Meakins A. Soft tissue sore spots of an
unknown origin (Br J Sports Med
2015;49:348). Adam Meakins was incorrectly titled as Dr in the correspondence
address of his paper.
Br J Sports Med 2015;49:1026.
doi:10.1136/bjsports-2014-094502corr1

Twitter Follow Daniel Parnell at @parnell_daniel

Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned;
internally peer reviewed.

To cite Parnell D, Curran K. Br J Sports Med

2015;49:1026.
Accepted 14 January 2015
Published Online First 2 February 2015
Br J Sports Med 2015;49:1026.
doi:10.1136/bjsports-2015-094582

REFERENCES
1

2
3

Rosenbaum S, Tiedemann A, Ward PB, et al. Physical

activity interventions: an essential component in
recovery from mental illness. Br J Sports Med
Published Online First: 18 Dec 2014 doi:10.1136/
bjsports-2014-094314
Parnell D, Richardson D. Introduction: football and
inclusivity. Soccer Soc 2014;15:8237.
Hunt K, Wyke S, Gray CM, et al. A gender-sensitised
weight loss and healthy living programme for
overweight and obese men delivered by Scottish

Bergeron MF. Training and competing in

the heat in youth sports: no sweat? (Br J
Sports Med 2015;49:8379). The change
to this authors professional afliation and
address for correspondence were not
updated during the production process.
The correct afliation is Youth Sports of
the Americas, Lemak Sports Medicine,
Birmingham, Alabama, USA. Correspondence address is Dr Michael F Bergeron,
Youth Sports of the Americas, Lemak
Sports Medicine, 720 Montclair Road,
Birmingham, Alabama, 35213 USA;
mbergeron.phd01@gmail.com.
Br J Sports Med 2015;49:1026.
doi:10.1136/bjsports-2015-094662corr1

Br J Sports Med August 2015 Vol 49 No 15