What Knot

by Matt

“What is that thing, anyway?”

I’m always getting asked this question. I’m a massage therapist, and “that thing” is a knot. But what’s a “knot”? The short answer is “I don’t fully know,” but I’m not fully convinced that anyone else does either. Given my experience and education I will try my best to explain what we’re talking about when we say “knot” in massage.

Embarrassingly, the word “knot” occupies a kind of conceptual no man’s land between clinical definition and common language. Basically, we know one when we see one, but no one really knows of what it is comprised, or what set of criteria its qualities must satisfy to be called a knot. There is no medical definition of a knot.

photo by woodleywonderworks

It would probably be more accurate for me to say that no one really agrees on every aspect of what constitutes a knot, how you get knots, and how to treat them. However everyone agrees that a knot forms in muscle tissue. This includes connective tissue such as fascia and maybe tendon. Blood almost certainly plays a role, as does our nervous system. They are raised from the rest of the surface, and sometimes they are tender.

Secondly, knots also tend to form in stressed or damaged muscle. Overdoing it in the gym or on the trail will certainly aid this, but most massage therapists I work with are more inclined to find knots in muscles associated with desk work. These associate with the commute and compute postural distresses of holding your head and arms away from your body for too long.

Knots, as we vaguely understand them, are also likely to form in stressed or challenged people. I don’t mean to overstep my scope of practice here, but I will simply observe that people undergoing emotional stress due to family, career, or other life events often are also going through emotional stress. I’m constantly hearing, “Oh I keep all my stress in my neck and shoulders.” And I often find knots up there.

In my experience adhesion between muscle fibers or muscles, trigger points, and/or some combination of the two commonly present as something we clumsily describe as a “knot.” The term is nonspecific and could refer to cases that are dissimilar in most other aspects, but knots of any variety are non-lethal. Massage, rest, stretching, detoxification, lifestyle changes all contribute positively to their mitigation, though there is some debate as to whether they can actually be removed. This is true for which ever classification of knot we describe.

Still, knots remain elusive to clinical definition. To my knowledge no one has tried to biopsy one, I don’t know if they show up in cadavers. Based on the indications for treatment from my perspective as a therapist, I suspect most knots are masses formed from thickened muscle tissue and attendant metabolic wastes and associate with the combination of adhesion and trigger points.

Some knots seem to invest more than one muscle tissue. Comprised of inflamed myofascial layers, and almost always including a concentrated degree of connective tissue, these knots feel gristly, and their size does not predict sensitivity to pressure. These knots tend to sound and feel “crunchy.” I’ve heard this crunchiness comes from either connective tissue build up or from calcium crystal build up. It may not even be associated with the muscle, but with the ribs underneath the tissue.

Knots that refer pain within the domain of a predictable pain pattern are more accurately described as trigger points, and I get the feeling that most practitioners and quite a few clients are really talking about trigger points when they are speaking about knots. Trigger points are germane to our weird little world where a phenomenon of objective anatomical pathology overlaps with the intellectual property of their namer, Dr. Janet Travel, but the medical field officially recognizes them.

Where knots are general, trigger points are specific, predictable, and often don’t even present as knots. I find the most common ones show up in the upper back and in the calves. Trigger points by definition form within tight bands of muscles in predictable locations, they grow in mass, sometimes produce greater heat, and are sensitive and painful to the touch. Frequently, the pain associated with a trigger point refer to other points in the body. In my opinion treating trigger points are clinically more significant than the general presentation of knots.

Most therapists will treat knots of any variety with localized pressure delivered directly to the knot. More sophisticated practitioners, whether from training or experience, will undoubtedly apply different techniques to your knots based on what they feel. Generally speaking, true trigger points respond better to direct pressure than the more gristly “adhesion” knots. Releasing trigger points in this way can relax the entire muscle. Adhesive knots seem to respond better to being “ironed” or “combed” out of the tissue. Sometimes separating one muscle from the other through movement can deal with those types of knots.

So, if you suffer from knots, be they trigger points or of a more general character, massage can certainly help. But keeping in mind that they seem to form in relation to how we use our bodies, I would also suggest taking the time to assess your lifestyle and how you inhabit your body throughout the day. You may be able to change a habit or arrangement so that you don’t form the knots as quickly in the first place.