When is a Knot Not?

Over the years many patients have come to see me with a self diagnosed “pulled muscle.”  The problem might be a pain in their back, neck, under a shoulder blade, or just about anywhere else. Thanks to a fair amount of inquisitive prodding and poking they are often aware of a tender knot in a muscle, right there in the region that hurts, so there is no doubt about the diagnosis, is there?

A “pulled muscle’ or to give it its Sunday name, a “muscle strain” is actually a tearing of muscle fibres. The tear is often produced by an over stretching of the muscle, much as you might tear a piece of cloth. An example is a slip on a muddy path, where one foot shoots forwards while the other one stays behind you.

Unlike cloth, muscles can also tear themselves. If they contract so strongly that they can’t stand the level of tension, something has to give. You may have seen an Olympic sprinter explode off the blocks only to pull up a few strides later grabbing at the back of their thigh and grimacing in agony. The contraction of the muscle has been so powerful that the muscle has pulled itself apart.

A pulled muscle will come on suddenly, usually with an obvious cause, and will be acutely painful. So long as nothing interferes with its natural recovery, such as re-pulling it again, it will gradually recover over a period of days, or if it is severe, possibly weeks. Severe tears often result in bruising as the muscle bleeds under the skin.

Most of the “pulled muscles” presented to me don’t fit this description at all, but that’s because they aren’t pulled muscles.

Very often the problem that the patient is suffering from has come on gradually, or has started with either no trauma, or with an insignificant amount of strain. “I stooped over the sink to brush my teeth and felt it go.”

In many cases, the most telling question I ask is “When did the problem start?” Frequently the answer is, “two or three months ago” which makes a pulled muscle an unlikely candidate, as all the King’s horses and all the King’s men should have put it back together again by now.

More often the problem involves joint dysfunction where the muscles holding the joint stiff are tightly bunched up, producing the tender “knot” that the patient’s inquisitive fingers have discovered. This is particularly common in spinal joints where the pain can be confusingly referred away from the spine. Pain hiding under shoulder blades, running down arms or legs or shooting up into the head are all common patterns.

Sometimes several structures have been trying to compensate for some repeated stress, and a complex pattern of dysfunction builds up making the problems rather more difficult to diagnose. This is commonly the case with the so called “frozen shoulder” for instance.

I love finding simple solutions when I can; it makes me look really clever! But if the problem is complex, we have to be careful about not looking for answers that are too oversimplified.