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Response to "Knot in a muscle' post
Mr. Gordon J. Wallis in his post “Knot in a muscle’ raised very important topic and it seems that members expressed variety of opinions. Considering the importance of the subject I decided to open separate discussion and put everything in the scientific perspective.
There are two types of 'knots' you may experience in your practice.
First is called hypertonus and it is usually associated with active trigger point(s). The correctly used trigger point therapy protocol will be able to completely eliminate this abnormality. The second type of the 'knots' is called myogelosis and it is irreversible degeneration of the muscle fibers you feel like 'marbles' in the tissue.
The core of myogelosis will stay with your clients for the rest of the life if it is already formed. However by itself it is usually painless if there is no direct pressure applied to it. At the same time uncontrolled myogelosis is very painful and responsible for a lot of tension because core is direct cause of the neighboring hypertonuses to form around it. This drives your clients crazy.
By the way incorrectly applied Trigger Point Therapy in the form of senseless application of pressure without finding the Entrance into the Trigger Point, using Compass Technique, Stop and Go Approach etc. is directly responsible for the excessive damage of the muscle fibers in the area of hypertonus and later formation of the myogelosis there.
If readers would like to learn how hypertonus, trigger point and myogelosis form, how to differentiate and diagnose them as well as how to treat them correctly using scientifically sounded protocol of Trigger Point Therapy please read our three part article on Trigger Point Therapy in
March/April: http://scienceofmassage.com/dnn/som/journal/0903/toc.aspx
May/June: http://scienceofmassage.com/dnn/som/journal/0905/toc.aspx
July/August: http://scienceofmassage.com/dnn/som/journal/0907/toc.aspx
2009 issues of Journal of Massage Science. This article will answer ALL of your questions in every detail.
If you read the article and need any clarifications you may post your questions here and I will be happy to answer them.
Sincerely Dr. Ross Turchaninov
Views: 7219
Replies to This Discussion
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Permalink Reply by Gary W Addis, LMT on
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Yes, since I didn't know what it was, I didn't try to "cure" a problem that may not have been a problem. I know that I did a lousy job of explaining what I was feeling.
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No, Ty, it absolutely was not a rib--or any other bone. I wrote so much about it that you may have missed it, but I did say the "mass" is not hard, just slightly denser than the surrounding tissue. And I definitely was not near the ribs, I was a lateral to the ribs and not that deep.
Not scalenes, and I don't think trapezius, so maybe it was the omohyoid. but then, the omohyoid is pretty deep in that area, isn't it? I cupped the tissue between fingers (feeling through trapezius, which were butter soft) and thumb coming over the top of the supine client; it definitely did not scoot away from me.
Ty said:Gary,
Just to weigh in on this - based on your description it sounds like you felt an elevated first rib on the right side. I would ask if she carrys a heavy purse on her left shoulder? I would pay attention to her breathing - belly breather or shoulder breather? It may not have "softened" as much as moved back into position. It would explain why everyone is finding the same thing. If you work on her again I would ask your instructor what technique he/she uses for 1st rib elevation.
TyGary W Addis said:
In the area with the mass, there is no pain, very little tonus. Have you ever made bread? As close an analogy as I can come up with is, the texture of the surrounding tissue is like first roll-out dough; of the mass, more like 2nd or 3rd roll out-- still pliable, but denser than the surrounding tissue. Now, the other side of both women was normal.
However, the older client complains of chronic tightness and limited ROM on the other side. She receives a full body every couple of weeks, and according to her SOAPs, she always has the same complaint.
Now, I may be giving the impression that this difference in tonus I'm reporting is quite noticeable. In both, I was giving particular attention to that area. While she was prone, I had found several TPS in the opposite side of the older lady, but nothing on the "mass" side; after repositioning to supine, I checked the traps and neck area of both sides again, and this is when I found the "mass.
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Permalink Reply by Dr. Ross Turchaninov on
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Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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You could be correct, but, really, I don't think so. I didn't dig down into it, but was able to grasp, and feel its borders, beneath and to the sides. I wasn't deep enough to be contacting a rib. Lying supine, her traps were supported by the table and were very soft, so I suppose it could have been the traps? I'm still thinking the omohyoid before it begins its vertical journey from the scapula into the anterior neck. If so, the muscle is thicker than I imagined.
It isn't something I am concerned about--both women seemed healthy and active, not buff but certainly not clinically obese. The student transferred to another class due to starting a new job, so I likely won't work on her again. But the older lady is a bi-weekly client, and I did please her, so I may see her again in a week or so. If so, I'll do more exploring, and try to define its borders. But, I promise, I won't attempt to "fix" what is unlikely to be a problem.
Thanks to everyone for the help. Here in MS it is 0146 and I have to begin dressing for class at 0600. I have a pathology test tomorrow, too.
Dr. Ross Turchaninov said:Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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Permalink Reply by Boris Prilutsky on
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Hi Gary.
Actually I like very much your definition in regards of what you are feeling at the time of soft tissue examinations . To me you are defining some new formation and as you described previously and because it got smaller in size after massaging it , most likely it is a cyst. And as I stated in my previous reply to you:” any new formation is prohibit to massage”. I agree with you that this is not an anatomical structure but some abnormals,because you: A) obviously feeling massB) as well couldn't find this mass on other site. Excellent way of thinking.not often, I would say rare, but abnormal mass can be found on both sides and at the same locations. In such a case it's still new formations and we do not massaging it.
I like very much the way you thinking. It is critical in our business.
Best wishes.
Boris
Gary W Addis said:
You could be correct, but, really, I don't think so. I didn't dig down into it, but was able to grasp, and feel its borders, beneath and to the sides. I wasn't deep enough to be contacting a rib. Lying supine, her traps were supported by the table and were very soft, so I suppose it could have been the traps? I'm still thinking the omohyoid before it begins its vertical journey from the scapula into the anterior neck. If so, the muscle is thicker than I imagined.
It isn't something I am concerned about--both women seemed healthy and active, not buff but certainly not clinically obese. The student transferred to another class due to starting a new job, so I likely won't work on her again. But the older lady is a bi-weekly client, and I did please her, so I may see her again in a week or so. If so, I'll do more exploring, and try to define its borders. But, I promise, I won't attempt to "fix" what is unlikely to be a problem.
Thanks to everyone for the help. Here in MS it is 0146 and I have to begin dressing for class at 0600. I have a pathology test tomorrow, too.
Dr. Ross Turchaninov said:Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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Dear friends.
As I have promised , offering you link to new issue Journal of massage science including but far not limited to my case presentation.This issue offering a lot of material to learn and discuss. You're welcome to post any questions as well your own opinion on different subjects .in agree/ disagree discussions we all will learn.
http://www.scienceofmassage.com/dnn/som/journal/1107/toc.aspx
Best wishes.
Boris
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Thank you for your input, Boris.
Boris Prilutsky said:
Hi Gary.
Actually I like very much your definition in regards of what you are feeling at the time of soft tissue examinations . To me you are defining some new formation and as you described previously and because it got smaller in size after massaging it , most likely it is a cyst. And as I stated in my previous reply to you:” any new formation is prohibit to massage”. I agree with you that this is not an anatomical structure but some abnormals,because you: A) obviously feeling massB) as well couldn't find this mass on other site. Excellent way of thinking.not often, I would say rare, but abnormal mass can be found on both sides and at the same locations. In such a case it's still new formations and we do not massaging it.
I like very much the way you thinking. It is critical in our business.
Best wishes.
Boris
Gary W Addis said:
You could be correct, but, really, I don't think so. I didn't dig down into it, but was able to grasp, and feel its borders, beneath and to the sides. I wasn't deep enough to be contacting a rib. Lying supine, her traps were supported by the table and were very soft, so I suppose it could have been the traps? I'm still thinking the omohyoid before it begins its vertical journey from the scapula into the anterior neck. If so, the muscle is thicker than I imagined.
It isn't something I am concerned about--both women seemed healthy and active, not buff but certainly not clinically obese. The student transferred to another class due to starting a new job, so I likely won't work on her again. But the older lady is a bi-weekly client, and I did please her, so I may see her again in a week or so. If so, I'll do more exploring, and try to define its borders. But, I promise, I won't attempt to "fix" what is unlikely to be a problem.
Thanks to everyone for the help. Here in MS it is 0146 and I have to begin dressing for class at 0600. I have a pathology test tomorrow, too.
Dr. Ross Turchaninov said:Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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Permalink Reply by Stephen Jeffrey on
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Hi Dr Ross,
thankyou for your reply, however, I must strongly disagree with your supposition that =
it will be always painful to touch
the reason I stated normally but not always painfull is because of the power of dissociation of pain =
http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...
Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)
Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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Stephen, as always a nice crisp apple to you. I appreciate your input in all things. Stephen, am I correct that fat interspersed in muscle will feel different than either will feel alone? What I palpated was firmed than the trapezius cap-- but the traps were under no tension, there flat on the table. It's been awhile now, and memory is trying to dredge up all kinds of confusing stuff. But the omohyoid arises from superior border of scapula into the hollow between the overlying traps and the clavicle--how deep I am unsure of. What I felt was a difference in density, certainly not like a separate band of muscle down in there. Both of these women are kinda...soft beneath the covering fascia (which when tight can make flab feel rather firm). Maybe that's all it is. Too big to be adhesion, and too pliable to be a cyst of some kind, and there was absolutely no reaction to the palpation from either woman. It's two unrelated women, so it ain't likely to be a growth that shouldn't be there. So, I' m gonna assume it's perfectly natural-- but I will get an instructor over if I find it again.
Stephen Jeffrey said:Hi Dr Ross,
thankyou for your reply, however, I must strongly disagree with your supposition that =
it will be always painful to touch
the reason I stated normally but not always painfull is because of the power of dissociation of pain =
http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...
Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)
Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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Hi Stephen
I think this matter of terminology. The Thoracic Outlet Syndrome(TOS) is always painful because it involves compression of brachial plexus and subclavian artery. The same condition in the same area but on the level of irritation of the same structures called Anterior Scalene Muscle Syndrome and isn't always painful. If let say Adson's test positive which is one of the signs of TOS the pain on the upper extremity is already there for sure.
To Gary
if you think that this mass in the trapezius itself it can me large myogelosis we discussed before. If there is no peripheral hypertonuses core of myogelosis will fill as a painless and movable mass.
Dr. Ross Turchaninov
Stephen Jeffrey said:Hi Dr Ross,
thankyou for your reply, however, I must strongly disagree with your supposition that =
it will be always painful to touch
the reason I stated normally but not always painfull is because of the power of dissociation of pain =
http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...
Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)
Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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Dr, the definition of myogelosis fits this as well as anything else I've heard. A large one, though. I'll leave it alone.
Dr. Ross Turchaninov said:
Hi Stephen
I think this matter of terminology. The Thoracic Outlet Syndrome(TOS) is always painful because it involves compression of brachial plexus and subclavian artery. The same condition in the same area but on the level of irritation of the same structures called Anterior Scalene Muscle Syndrome and isn't always painful. If let say Adson's test positive which is one of the signs of TOS the pain on the upper extremity is already there for sure.
To Gary
if you think that this mass in the trapezius itself it can me large myogelosis we discussed before. If there is no peripheral hypertonuses core of myogelosis will fill as a painless and movable mass.
Dr. Ross Turchaninov
Stephen Jeffrey said:Hi Dr Ross,
thankyou for your reply, however, I must strongly disagree with your supposition that =
it will be always painful to touch
the reason I stated normally but not always painfull is because of the power of dissociation of pain =
http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...
Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)
Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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Hi Dr Ross Turchaninov
I am saying whatever the terminology, whatever the syndrome, whatever the test, however likely pain is to be the "normall experience", we need to keep in mind the dissociation phenomena in human pain experience.
Dr. Ross Turchaninov said:Hi Stephen
I think this matter of terminology. The Thoracic Outlet Syndrome(TOS) is always painful because it involves compression of brachial plexus and subclavian artery. The same condition in the same area but on the level of irritation of the same structures called Anterior Scalene Muscle Syndrome and isn't always painful. If let say Adson's test positive which is one of the signs of TOS the pain on the upper extremity is already there for sure.
To Gary
if you think that this mass in the trapezius itself it can me large myogelosis we discussed before. If there is no peripheral hypertonuses core of myogelosis will fill as a painless and movable mass.
Dr. Ross Turchaninov
Stephen Jeffrey said:Hi Dr Ross,
thankyou for your reply, however, I must strongly disagree with your supposition that =
it will be always painful to touch
the reason I stated normally but not always painfull is because of the power of dissociation of pain =
http://sciconrev.org/2008/10/pain-dissociation-and-subliminal-self-...
Gary! there are no absolutes "always" in palpation/massage we sometimes have to feel the pain/condition of the tissues that the client themselves cannot feel due to dissociation or other factors. Your intuition is serving you so, so, well, again I say hats off to you. (I award you many good apples :)
Hi Gary
Sorry for the delay in answering. If this mass doesn't have any pathological origin (e.g. Lymphoma) the first what comes into the mind is cervical ribs. In such case the scalene posterior and levator scapula muscles bend over the cervical rib and it may feel as a laterally located mass which is actually muscle belly pushed laterally by the cervical rib. It will be painless during palpation.
Stephen mentioned Throacic Outlet Syndrome and in fact the spasm in the anterior scalene may feel as a bulge but it will be always painful to touch and pain will radiate to the upper extremity. Other wise it is not the Thoracic Outlet.
Dr. Ross
Stephen Jeffrey said:Hi Gary I know you are asking Dr Ross so hope you don't mind me jumping in.
Could it be thoracic outlet syndrome? When the head of the first rib has been in chronic elevation the surrounding muscles and neurovascular structures can sometimes palpate as you describe but are normally (but not always) painfull.
I know you are doing a NMT class, and there is pressure on you to work site specific (neck upper back), so maybe outside class use whatever techniques you have to release the hypertonic/fibrotic tissue/fascia in the arms and hands (reflexes).
Releaseing the arms/hands before working neck will get you even better results that last longer and greatly reduce the risk of over working the neck as Therese reported in another thread.
Hope this helps
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