Soft tissue sore spots of an unknownoriginAdam Meakins

Trigger points are common clinical diagno-ses in the musculoskeletal profession.However, questions have been raised aboutwhat they are and how they are treated.1

Trigger points were first described by Travelland Simons as tender, painful areas found inmyofascial tissue when palpated. These areoften described as muscle ‘knots’ or tautbands, and are considered to be areas ofadverse sustained muscular contractioncaused either from direct trauma to myofas-cial tissue or through repeated microtraumafrom postural or activity-related stresses/strains. This is believed to cause a crisis atthe motor end plates, creating a sustainedadverse muscular contraction that is then feltas pain either locally or referred elsewhere.

However, despite widespread acceptanceof this theory, and a large and diverseindustry built around the treatment oftrigger points, including various deep tissuemassage and acupressure techniques andmore recently, the growing popularity ofdry needling, the theory of adverse muscleknots and taut bands as a cause of soft tissuepain has never been adequately explained.

SO WHAT ARE THEY?More and more clinicians question theaccepted explanations for trigger points inthe light of growing research and under-standing in neurophysiology and painscience. It is questionable if trigger pointsare adverse areas of sustained contractionin muscles for a number of reasons andalternative causes of trigger points, suchas peripheral neural inflammation orischaemic tissues, may be more likely.2

The acceptance of knots in muscles neversat well with me. As a young physiotherap-ist, I regularly infuriated my educators asthey attempted to teach me how to palpatetrigger points, but despite provoking pain Icould never feel anything adverse. Perhapsit was my lack of skill or experience in pal-pation; however, over a decade later, I canstill confidently say that I have never felt atrue trigger point.

When I discuss this with other therapistsit seems that I am in a minority. Nearly allother therapists I speak to tell me that theyhave felt adverse knots from time to time,and they tell me I simply need more

training. Maybe they are right; maybe I justhave sausage fingers that cannot palpate any-thing. However, there is evidence that eventhe world’s leading experts are also unableto accurately or reliably locate triggerpoints.3 If these experts cannot find them,then what chance do the rest of us have?

SO WHAT ABOUT THE EVIDENCE?Studies have tried to visualise trigger pointsusing MR elastography, sonoelastography orDoppler ultrasound. However, these studiesare of poor quality, lacking in control groupsor descriptions of how they classified, diag-nosed or located the trigger points.4

Tissue biochemistry research has beenconducted around trigger points, and ele-vated levels of inflammatory and neuro-transmitter chemicals have indeed beenfound.5 However, control tissue sampleswere similar.Electromyography (EMG) studies have

reported adverse electrical activity in andaround trigger points.6 These very small ele-vated EMG spikes, however, cannot be reli-ably distinguished from background latentnoise or artefacts from the fine, wire needles.Dry needling for treatment of trigger

points has scant evidence; studies have poormethods and high risk of bias. The proposedmechanism for dry needling is the needlepoint disrupts the motor end plate crisis bystimulating the neural tissue. However,demonstrated trigger points have not beenshown to be adverse muscle contractionscaused by motor end plates in crisis. So thisexplanation is highly questionable.The temporary pain reducing effects

often seen with painful treatments, such asdry needling, can be attributed to otherwell-known neurophysiological processes,such as diffuse noxious inhibitory control,and other non-specific psychologicaleffects, for example, the patient’s expecta-tions and placebo effects.7 It is also worthremembering that pain is a complex phe-nomenon. Just because pain is palpated at alocation does not mean that this location isthe source of pain, and when a treatment isdelivered to a structure and it relieves pain,this still does not mean this structure wasthe source of pain.

SO WHAT ARE WE PALPATING THEN?The phenomenon of pareidolia can, Ibelieve, explain what therapists are ‘feeling’when they palpate for trigger points.Pareidolia is defined as vague and obscure

stimulus that is perceived as something clearand distinct. For example, a therapist’s beliefor expectation that they will find a triggerpoint can and does cause them to palpateperfectly normal anatomy and interpret it asan abnormal trigger point. Pareidolia is actu-ally a common phenomenon throughout themusculoskeletal professions and occurs dueto multiple factors, such as past experiences,personal preferences and preconceptions.8

In summary, alternate theories of whattrigger points are do exist. They explainwhy we often see patients with soft tissuepain that is painful on palpation, but notwhy we cannot reliably or accurately feelknots or taut bands. However, it must berecognised that these alternative theoriesalso lack any robust evidence and manyquestions remain still unanswered. In lightof this uncertainty, I suggest that we shouldnot be explaining trigger points as muscleknots, but rather that they are simply softtissue 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

REFERENCES1 Quintner JL, Bove GM, Cohen ML. A critical evaluation

of the trigger point phenomenon. Rheumatology2014:pii: keu471. Published Online First.

2 Quintner JL, Cohen ML. Referred pain of peripheralnerve origin: an alternative to the “myofascial pain”construct. Clin J Pain 1994;10:243–51.

3 Wolfe F, Simons DG, Fricton J, et al. The fibromyalgiaand myofascial pain syndromes: a preliminary study oftender points and trigger points in persons withfibromyalgia, myofascial pain syndrome and nodisease. J Rheumatol 1992;19:944–51.

4 Chen Q, Bensamoun S, Basford JR, et al. Identificationand quantification of myofascial taut bands withmagnetic resonance elastography. Arch Phys MedRehabil 2007;88:1658–61.

5 Shah J, Danoff J, Desai M, et al. Biochemicalsassociated with pain and inflammation are elevated insites near to and remote from active myofascial triggerpoints. Arch Phys Med Rehabil 2008;89:16–23.

6 Simons DG, Hong CZ, Simons LS. Endplate potentialsare common to midfiber myofacial trigger points. Am JPhys Med Rehabil 2002;81:212–22.

7 Sprenger C, Bingel U, Büchel C. Treating pain withpain: supraspinal mechanisms of endogenousanalgesia elicited by heterotopic noxious conditioningstimulation. Pain 2011;152:428–39.

8 Foye P, Abdelshahed D, Patel S. Musculoskeletalpareidolia in medical education. Clin Teach2014;11:251–3.

Correspondence to Dr Adam Meakins, Departmentof Physiotherapy, Spire Bushey Hospital, HeathbourneRoad, Bushey, Herts WD23 1RD, UK;adammeakins@hotmail.com

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

Editorial

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Soft tissue sore spots of an unknown origin

Adam Meakins

doi: 10.1136/bjsports-2014-0945022015 49: 348 Br J Sports Med 

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To cite Elliott A, La Gerche A. Br J Sports Med2015;49:1025–1026.

Accepted 20 January 2014Published Online First 19 December 2014

▸ http://dx.doi.org/10.1136/bjsports-2014-094363

Br J Sports Med 2015;49:1025–1026.doi:10.1136/bjsports-2014-094441

REFERENCES1 Leischik R. Myths of exercise induced right ventricular

injury: the bright side of the moon. Br J Sports Med2015;49:636.

2 Teske AJ, Prakken NH, De Boeck BW, et al.Echocardiographic tissue deformation imaging of rightventricular systolic function in endurance athletes.Eur Heart J 2009;30:969–77.

3 La Gerche A, Heidbuchel H. Can intensive exerciseharm the heart? You can get too much of a goodthing. Circulation 2014;130:992–1002.

4 Heidbuchel H, Hoogsteen J, Fagard R, et al. Highprevalence of right ventricular involvement inendurance athletes with ventricular arrhythmias. Roleof an electrophysiologic study in risk stratification.Eur Heart J 2003;24:1473–80.

5 Benito B, Gay-Jordi G, Serrano-Mollar A, et al.Cardiac arrhythmogenic remodeling in a rat model oflong-term intensive exercise training. Circulation2011;123:13–22.

Professional football clubscould deliver pragmaticphysical activity interventionsto promote mental health

Rosenbaum et al1 provide evidence of theimportance and potential benefits of usingphysical activity interventions for the treat-ment of mental illness. The authors high-lighted the need for pragmatic physicalactivity interventions. This letter introducesthe role of professional football clubs.

Professional football clubs have delivereda variety of community-based interventions.Clubs programmes have engaged hard-to-reach populations across the lifespan,2

supported clinically significant weight

reduction through cost-effective interven-tions.3 This approach offers potential fordelivering benefits for health and socialwell-being4 for participants with a mentalillness.5

As the financial cost of mental illness issubstantial, we concur with Rosenbaumet al1 that it is vital to consider pragmaticand novel approaches for promotingphysical activity. Professional footballclubs’ community interventions add afurther opportunity for policymakers,commissioners and applied practitionersto translate existing evidence to tacklemental illness.

Daniel Parnell, Kathryn Curran

Leeds Beckett University, Centre of Active Lifestyles,Leeds, UK

Correspondence to Dr Daniel Parnell, Leeds BeckettUniversity, Centre of Active Lifestyles, HeadingleyCampus, Carnegie Faculty, Leeds L36 3QS, UK;d.parnell@leedsbeckett.ac.uk

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 Med2015;49:1026.

Accepted 14 January 2015Published Online First 2 February 2015

Br J Sports Med 2015;49:1026.doi:10.1136/bjsports-2015-094582

REFERENCES1 Rosenbaum S, Tiedemann A, Ward PB, et al. Physical

activity interventions: an essential component inrecovery from mental illness. Br J Sports MedPublished Online First: 18 Dec 2014 doi:10.1136/bjsports-2014-094314

2 Parnell D, Richardson D. Introduction: football andinclusivity. Soccer Soc 2014;15:823–7.

3 Hunt K, Wyke S, Gray CM, et al. A gender-sensitisedweight loss and healthy living programme foroverweight and obese men delivered by Scottish

Premier League football clubs (FFIT): a pragmaticrandomised controlled trial. Lancet 2014;383:1211–21.

4 Henderson C, O’Hara S, Thornicroft G, et al. Corporatesocial responsibility and mental health: the PremierLeague football Imagine Your Goals programme. IntRev Psychiatry 2014;26:460–6.

5 Pringle A, Zwolinsky S, McKenna J, et al. Healthimprovement for men and hard-to-engage-mendelivered in English Premier League football clubs.Health Educ Res 2014;29:503–20.

CORRECTIONS

Meakins A. Soft tissue sore spots of anunknown origin (Br J Sports Med2015;49:348). Adam Meakins was incor-rectly titled as Dr in the correspondenceaddress of his paper.

Br J Sports Med 2015;49:1026.doi:10.1136/bjsports-2014-094502corr1

Bergeron MF. Training and competing inthe heat in youth sports: no sweat? (Br JSports Med 2015;49:837–9). The changeto this author’s professional affiliation andaddress for correspondence were notupdated during the production process.The correct affiliation is Youth Sports ofthe Americas, Lemak Sports Medicine,Birmingham, Alabama, USA. Correspond-ence address is Dr Michael F Bergeron,Youth Sports of the Americas, LemakSports 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

1026 Br J Sports Med August 2015 Vol 49 No 15

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