Detailed guides to painful problems, treatments & more

Articles Index

A searchable, sortable list of all featured articles and guides on PainScience.com

See also: indexes of articles by condition, treatment or concepts & principles • the blog (short posts only) • sitemap • what’s new
 

Type topics like “back pain” or “stretching” into the search box. Keywords are suggested as you type — choose one, or ignore them and type anything.EXAMPLEExample: To find featured and controversial articles about back pain, you want to enter “featured, back, controversial” — but you don't have to type it all. First type “feat” and then press enter to autocomplete the “featured” keyword. The list now only contains featured articles. Now type “bac” and press enter to completed the “back” tag. Finally type “contr” and choose the “controversial” keyword. The list now contains more than 200 articles that each have at least one of these tags, but the ones with two or three sort to the top. The list always sorts to show the best matches for your search at the top, but you can re-sort the list. There are many tags, like “fun” and “research.” MORE TAGSTag (keyword) suggestions popup as you type. Start typing knee pain and you’ll see that there are many items about knee pain! There are many other subject matter tags for all kinds of painful problems, like back pain, more for treatments like massage or chiropractic, plus dozens of other kinds of tags. Try typing size to pick a size tag. Searching for featured articles is a good way of finding the best. Some other useful tags are tags for specific areas: leg, head, knee, etc. Or tags for the tone of a post: fun, debunkery, deep for mind blowing items.

The Complete Guide to Chronic Tension Headaches+

Headaches are one of the top 10 most disabling conditions and about 50% of us get tension headaches. Migraines involve the brain and are usually worse (but not always), tend to throb only one side, and cause some stranger symptoms. There are many other types of headaches and a firm diagnosis is nearly impossible. Any unusually severe, persistent, sudden, or strange headache needs medical investigation.

Tension headaches have dozens of possible causes, but are associated with stress, fatigue, and neck pain, and are probably mainly caused by pain spreading from sensitive structures in the neck, face, jaw, and scalp, especially the suboccipital muscle group. Self-massage there is the most neglected easy treatment option.

Other promising treatments include relaxation, meditation, breathing exercise, insomnia treatment, and building neck strength. Many popular treatments are ineffective, most notably pain-killers, which can even backfire; hydration, postural correction, chiropractic adjustment are also over-rated.

  A detailed, science-based tour of stubborn headache diagnosis and treatment, for both patients and professionals
updated   Oct 16, 21Oct '21 52,000
The Complete Guide to Muscle Strains+

Got a muscle strain? Maybe … and maybe not. Probably 75% of so-called muscle strains are actually something else. Doctors routinely diagnose muscle strain incorrectly. The muscle strain tutorial is guaranteed to sort it out … and it is just about only the source of information that does. For the majority of readers who’ve been misdiagnosed, the muscle strain tutorial comes with a free bonus tutorial about the problem they most likely do have — myofascial trigger points.

  Muscle strain (pulled muscle) and muscle pain explained and discussed in great detail, plus every imaginable treatment option
updated   Oct 14, 21Oct '21 34,000
The Complete Guide to Neck Pain & Cricks+

Who hasn’t had a crick in the neck? This tutorial isn’t the last word on this surprisingly complex subject, but it is a detailed, sensible and scientific survey of what makes a neck crick tick — and your treatment options. Ideal for any frustrated patient with a jammed cervical spine, it’s also helpful for many a therapist not really sure how to treat this quirky phenomenon. Comes with a free bonus, PainScience.com’s valuable trigger point tutorial!

  An extremely detailed guide to chronic neck pain and the disturbing sensation of a “crick”
updated   Oct 14, 21Oct '21 112,500
Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome   Perfect Spot No. 7, the masseter muscle of the jaw updated   Oct 14, 21Oct '21 4,250
The Complete Guide to Trigger Points & Myofascial Pain+

Myofascial trigger points — so-called “muscle knots” — are increasingly recognized as a factor in many of the world’s aches and pains. This book-length tutorial focuses on advanced troubleshooting for patients who have failed to get relief from basic tactics, but it’s also ideal for starting beginners on the right foot, and for pros who want to stay current and as science-based as possible. 180 sections inspired by the famous texts of Drs. Travell & Simons, but also much more recent science. Also offered as a free bonus (2-for-1) with the low back, neck, muscle strain, or iliotibial pain tutorials.

  An extremely detailed guide to the unfinished science of muscle pain, with reviews of every theory and treatment option
updated   Oct 9, 21Oct '21 207,500
Pain is Weird+

Modern pain science shows that pain is as hard to predict or control as the weather, a function of countless chaotic variables, a volatile sensation that is surprisingly disconnected from many seemingly “obvious” causes of pain. There are many fascinating cases of relatively painless trauma, and relatively trauma-less pain. Pain is not just jostled by many systemic variables, but especially the potent perceptual filters of the brain.

Pain is 100% brain-generated, and threat signals from damaged tissues are only one factor of many that the brain integrates before we experience the pain. The brain thoroughly “tunes” pain, and often even overprotectively exaggerates it — so much so that a false alarm tendency (“sensitization”) can be more serious and chronic than whatever triggered the alarm in the first place.

None of this means that pain is “all in your head,” but it does mean that psychology and context has a profound influence on pain. If the brain controls all pain, does that mean that we can think pain away? Probably not, because conscious minds are not the boss of our much busier brains. However, we do have some “neurological leverage” — we can probably influence pain, indirectly, if only we understand it.

Patients and professionals alike need to get past the simplistic notion that pain is a reflexive and proportionate reaction to tissue insult. It’s routinely weirder than that.

  Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues
updated   Oct 8, 21Oct '21 11,000
Does Posture Matter?+

Posture matters a little, but not a lot. Many habitual postures are the result of long-term adaptations to anatomical quirks, and it’s difficult and even unwise to try to change them. Most other so-called “poor posture” is actually just awkward adaptation to bad ergonomics, which involves postural stress but isn’t poor posture per se. Although many people do seem to be vulnerable to physical stresses, including postural stress, the most relevant and fixable problem is probably the unusual vulnerability, not the posture. Healthy people should be able to easily tolerate mild to moderate postural stress.

If your main issue is unexplained or stubborn aches and pains, working on posture is not the best way to spend your time: just get more exercise generally, especially tasks that require coordination, and anything you enjoy (inspiration, not discipline). “Advanced” methods taught by posture gurus and “posturologists” are mostly completely speculative nonsense.

  A detailed guide to posture and postural correction strategies (especially why none of it matters very much)
updated   Oct 6, 21Oct '21 18,000
The Science of Pain-Killers   A user’s guide to over-the-counter analgesics like acetaminophen, ibuprofen, and more new   Sep 27, 21Sep '21 3,250
Mind Over Pain+

Modern pain science shows that pain is a volatile, complex sensation that is thoroughly tuned by the brain. It functions as an overprotective warning system. Pain is completely brain-generated, and signals from damaged tissues are only one factor of many that the brain uses to create the experience of pain.

Does this mean that we can think pain away? Probably not, because conscious minds are not the boss of our much busier brains. However, we do have some “neurological leverage” of great value — we can influence pain, indirectly, if we understand it. This overlaps with lifestyle medicine, but it’s distinct from it: it’s about tinkering with pain perception itself.

The challenge is to convince our brains that there’s no need for an alarm. Just explaining pain itself to patients may reassure them that the danger implied by pain — especially chronic pain — is often greatly exaggerated. But explaining pain is hard and often backfires, treating patients like they just need a better “attitude” about their pain. Fortunately, there are many rational self-help options to pursue: education, rejecting “scary” diagnostic theories, treating anxiety and reducing sources of stress, creating sensory pleasures, seeking helpful social contexts, limiting “drama” and pain talk, positive movement, and many more.

None of these tactics are easy or proven paths to pain relief, but they all have potential, and are grounded in modern pain science.

  Pain can be profoundly warped by the brain, but does that mean we can think the pain away?
new   Sep 17, 21Sep '21 17,000
Vaginismus   The psychology, biology, and pain science of vaginal penetration pain disorders updated   Sep 15, 21Sep '21 8,000
Complete Guide to Low Back Pain+

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 583 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Comes with a free copy of PainScience.com’s trigger point tutorial!

  An extremely detailed guide to the myths, controversies, and treatment options for low back pain
updated   Sep 11, 21Sep '21 167,500
Achilles Tendinitis Treatment Science   Evidence-based guidelines for the fastest possible recovery updated   Sep 11, 21Sep '21 7,000
The Complete Guide to Patellofemoral Pain Syndrome+

PFPS is a common kneecap pain problem — and yet almost universally misunderstood. Patients are often given exactly the wrong advice. There is no miracle cure for patellar pain, but this tutorial is much more detailed than anything else you can find, weighing in at 40,000 words. Both patients and pros can greatly improve their understanding of the options — and maybe that is a kind of miracle. Inspired by the work of surgeon Scott Dye and firmly grounded in readable analysis of the science.

  An extremely detailed guide to rehab from patellofemoral pain syndrome (aka runner’s knee), with thorough reviews of every treatment option
updated   Sep 10, 21Sep '21 105,000
A Rational Guide to Fibromyalgia+

Fibromyalgia is an unexplained and mostly untreatable illness of chronic pain, fatigue, and mental fog affecting about 1–2% of the population. Some recover naturally. The label is often not used when it should be and also often used when it shouldn’t. Fibromyalgia is associated with (and may be related to) conditions like irritable bowel syndrome, migraines, mood disorders, inflammatory arthritis, and especially the pain of “trigger points” (sensitive patches of muscle). Its many non-specific symptoms are routinely confused with many more conditions.

Controversy, stigma, quackery, and junky science swirl around fibromyalgia like a bad smell. No medical speciality specializes in it. Rheumatologists and neurologists often get “stuck” with fibromyalgia patients, and have no idea what to do with them. Alternative medicine has flooded the knowledge gap with many bogus theories and related cures, like excess phosphate, adrenal fatigue, or “bad energy.” Many pros still assume fibromyalgia is “all in your head” or a character weakness, but studies have shown that fibromyalgia does have a biological fingerprint.

Fibromyalgia is a bigger medical puzzle than cancer, and there is no proven treatment. Regular moderate exercise seems to be helpful for some, but can backfire. Patients need to stay as healthy as possible otherwise, especially protecting sleep as much as practical, and avoiding drugs/alcohol/smoking. Vitamin D supplementation is a worthwhile experiment for many. No medications are known to be helpful.

  The science of the mysterious disease of pain, exhaustion, and mental fog
updated   Sep 10, 21Sep '21 22,000
Medical Errors in Perspective+

Alternative medicine practitioners often point accusingly to medical error rates with the implication that their services are much safer. That’s probably true, in the sense that walking is much safer than driving. But if your profession had to treat huge numbers of people with dire injuries and illnesses, it would also have scary error rates.

Bad things do happen in hospitals, and stats about iatrogenic (doctor-generated) medical errors can seem alarming. However, to simply state that medicine kills and hurts people is unethical fear-mongering. Cars kill and hurt people too, and for pretty much the same reason: sure it’s risky, but the benefits are worth the risk, and huge numbers of people are willing to take that chance.

Medical systems deal with vastly greater numbers of much more serious cases than any chiropractor or naturopath, and many of them are no-win, rarely-win, or sometimes-lose situations with the highest stakes, terrible suffering and death. We should be cautious about criticizing that from the outside. Try working in a hospital for a while, try to be perfect, try to never have anything go wrong that matters!

  Medical error rates have been exaggerated by a popular myth and should not be used to spread fear, uncertainty and doubt
updated   Aug 31, 21Aug '21 1,800
MRI and X-Ray Often Worse than Useless for Back Pain+

When it comes to diagnosing low back pain, MRI and X-Ray are egregious false alarm generators. Results are often so misleading that they are worse than useless out of clinical context. Wise use of imaging is a superpower, especially MRI, but it’s often used irresponsibly; overuse and abuse of the technologies is an over-medicalization disaster, criticized for since at least as far back as the 1990s.

Low back pain (like most chronic pain) is extremely multifactorial, and the spinal glitches that imaging reveals are just one ingredient in a rich stew of risk factors. Zooming in on what MRIs can show is doomed to diagnostic failure, a classic “streetlight effect” mistake: focusing only where the light is good. Imaging makes it easy to focus on what seems important: the spine. But spines usually look worse than they are. Seemingly serious spinal degeneration is found in high percentages of asymptomatic people. Zooming in it is not only doomed to diagnostic failure, but it can spook people and do real harm, because nothing is more clearly worse for back pain than anxiety.

There are also huge quality control problems with MRI, just shoddy work, like bizarrely conflicting results for the same patient from ten different MRI facilities — laughable if it weren’t so tragic.

So how should imaging be used? Minimally! Only when it’s strongly indicated by persistent major symptoms, and interpreting results only in clinical context. Patients should politely refuse early MRI and privately resolve to take radiology reports with a huge grain of salt.

  Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms
updated   Aug 27, 21Aug '21 3,000
Cold Laser Therapy Reviewed   A critical analysis of treating pain and injury with frickin’ laser beams updated   Aug 11, 21Aug '21 4,250
Cramps, Spasms, Tremors & Twitches+

There are about a dozen major known types of unwanted muscle contractions — cramps, dystonia, fasciculations, and myokemia, etc — and many popular ideas about them are wrong or no more than half-right. For instance, exercise-induced cramps are not caused by dehydration, “stiffness” is rarely caused by tight muscles, and muscles don’t actually go limp in anaesthesia. There’s no such thing as a “back spasm,” no vicious cycle of “pain-spasm-pain,” and no “protective spasm.”

Although pathological contractions can obviously cause great suffering, no one knows if there’s such a thing as a “subtle” cramp in otherwise healthy people: bad enough to hurt, but not large or strong enough to be otherwise felt or seen (like a typical calf cramp, which cannot really be missed). Such a type of cramp might explain a lot of common aches and pains, but the topic has not been well-explored scientifically.

  The biology and treatment of unwanted muscle contractions
updated   Aug 11, 21Aug '21 8,000
34 Surprising Causes of Pain   Trying to understand pain when there is no obvious explanation updated   Aug 5, 21Aug '21 14,000
Chronic Pain as a Conditioned Behaviour+Can chronic pain be a “learned response” (classical conditioning) to things that shouldn’t hurt, like Pavlov’s dogs salivating to the ring of a bell? It’s an interesting idea, with obviously optimistic implications, because what is learned might also be un-learned. If so, it’s a bit of a brain hack, a clever and surprising solution around one of the hardest problems there is. It’s a bit unlikely, but so interesting that it’s worth discussing and exploring.   If pain can be learned, perhaps it be unlearned updated   Jul 31, 21Jul '21 4,000
Reassurance for Massage Therapists+

There are some major issues with massage therapy that many massage therapists are unaware of: extensive pseudoscientific nonsense and amateurism in the profession. PainScience.com shines a bright light on those issues, and that has crushed the spirits of some massage therapists — even the most progressive and science-respecting ones. What really tugs at my heart strings is that they aren’t necessarily even disagreeing about the problems in the profession, but just feeling awful about agreeing with me. Ouch!

This article tries to do some damage control, and lift those spirits back up. Here are some of the key points of reassurance for massage therapists:

  • Massage is pleasurable and relaxing regardless of whether it has any other specific therapeutic effects, and pleasure and relaxation are inherently valuable. Some massage therapists feel let down by the idea that massage is “just” luxurious, but they shouldn’t.
  • Touch is profound for primates, and massage can probably inspire and facilitate personal growth and awareness in ways that are extremely difficult or impossible to deconstruct, test, and/or even define.
  • Evidence-based medicine isn’t paralyzed by imperfect or incomplete evidence, and massage therapy doesn’t have to be either; uncertainty is normal in healthcare, and there are good and bad ways of coping with it. The good ways can be learned.
  • Skeptics are generally bright and mostly correct about the major myths of massage therapy… but they are not remotely right every time they pipe up, and I have seen some seriously embarrassing, amateurish skepticism about massage.
  • Good health care is a process that is greater than the sum of its parts, rather than just a “service” or “product.” There is a bottomless pit of opportunity to make massage just one part of a process that is probably greater than the sum of it parts.

  How ethical, progressive, science-respecting massage therapists can thrive in a profession badly polluted with nonsense
updated   Jul 29, 21Jul '21 2,750
Does Fascia Matter?+

Fascia is widely regarded as an exciting scientific frontier, with well-attended fascia conferences featuring gurus in the world of massage and manual therapy. The main idea is that fascia — tough connective tissue wrapping around all muscles and organs — can get tight and restrictive, and needs to be “released” by pulling on it artfully. Unfortunately, although fascia science may be inherently interesting as biology, and fascial compartment syndrome is certainly a real and scary medical problem, no subtle property of fascia has yet been shown to be clinically relevant to anything. No fascial pathology seems to be a factor in any common painful problem, and no method of fascial manipulation is known to have any effect on fascia whatsoever, let alone “fix” it’s hypothetical problems.

I have challenged fascia fans to cite clinically relevant fascia science, with no result for years now. This article reviews several key candidates, such as well-known studies about fascia’s toughness, its contractility, and its role in back pain. None remotely confirm any clinical importance, and some actually undermine it. I also cover many other related subtopics, such the irrelevance of piezoelectricity, thixotropic effect, the popular “fuzz” theory of stiffness, and much more.

  A detailed critical analysis of the clinical relevance of fascia science and fascia properties
updated   Jul 19, 21Jul '21 30,000
Zapped! Does TENS work for pain?+

Transcutaneous electrical nerve stimulation (TENS) tries to treat pain by passing alternating current through superficial tissues causing tingling sensations, with brief and minor benefits that are probably just a “sensation-enhanced” placebo. It has been a therapeutic staple in physical therapy and chronic pain clinics for decades, and there are many consumer TENS gadgets. They are safe and fairly cheap at about $100 for a typical TENS unit.

It’s not as scientific as it seems, but it may not be useless either: interesting sensations can always get something done when presented in the right way to patients. The tingling and vibrating might “drown out” pain, “distract” the nervous system from it, or get the brain to “reconsider” pain. It’s remotely possible that TENS stimulates actual tissue behaviour change (healing) and not just sensation. In theory, the right setting could make all the difference, which makes the topic endlessly debatable, even though most TENS obviously doesn’t work many miracles.

There’s not much evidence that TENS helps pain and it’s surprisingly well-studied as these things go. Despite this, some experts remain remain optimistic that the right TENS for the right kind of pain could still be good medicine.

There are many other electrotherapies. Electrical muscle stimulation (instead of nerve) might help keep muscles fit during rehab from injuries. Pulsed electromagnetic field therapy (PEMF) is a fascinating cousin of TENS that might stimulate cellular repair. Spinal cord and brain stimulation using surgically implanted electrodes is basically “deep TENS.” Old-timey galvanic baths were whole body stimulation, “spasm baths” with no clear purpose. People do seem like to like shocking themselves!

  The peculiar popularity of being gently zapped with electrical stimulation therapy
updated   Jul 8, 21Jul '21 9,000
The Myth of Healing Hands+

Therapeutic touch (TT) is hands-off aura massage, actual touch not included, and it is the most common form of energy or vitalistic medicine in North America. Most practitioners are massage therapists and, oddly, nurses. Many years ago I believed in it, but eventually I decided it was based only on wishful thinking, laughably naive references to quantum physics, and wide-eyed exaggeration of ordinary social interaction effects. Auras do not exist and cannot be felt, let alone manipulated therapeutically. Just as dousers and psychics have never passed a controlled test, TT practitioners cannot detect a person by feeling their aura, which makes them look ridiculous.

It is peculiar and pleasant to have someone wave their hands all around you with friendly intentions, but those effects are minor and fleeting and it doesn’t matter what specifically the therapist does, because it’s the interaction that is the active ingredient — a placebo, in short. And placebo is nowhere near as “powerful” as people believe, and there are all kinds of ethical and practical problems with cluttering up the interaction with magical interpretations of what’s going on.

  Reiki, therapeutic touch, and other “energy medicine” methods are culturally rich but scientifically bankrupt
updated   Jul 2, 21Jul '21 3,750
Does Craniosacral Therapy Work?+

Craniosacral therapy (CST) was founded by an osteopath, John Upledger, and it is mainly done by osteopaths, massage therapists, and a few chiropractors. It’s a “subtle” therapy that involves light holding of the skull and sacrum and almost imperceptible manipulations. Supposedly this affects the circulation of cerebrospinal fluid and has profound therapeutic benefits. Recent, good quality scientific research has shown that it is not possible to affect the circulation of cerebrospinal fluid, and that CST therapists often come to different conclusions when evaluating the same patient. Even the journal of Complementary Therapies in Medicine “found insufficient evidence to support CST,” and Dr. Steve Hartman — an osteopathic physician himself — harshly criticizes CST: “Craniosacral therapy lacks a biologically plausible mechanism, shows no diagnostic reliability, and offers little hope that any direct clinical effect will ever be shown … patients should invest their time, money, and health elsewhere.” Virtually the only thing CST is good for is that it is a relaxing touch therapy, but of course that can (and should) be separated from grandiose claims of therapeutic efficacy.

  Craniosacral therapists make big promises, but their methods have failed to pass every fair scientific test of efficacy or plausibility
updated   Jul 2, 21Jul '21 4,750
Does Massage Therapy Work?+

Therapeutic massage is expensive but popular and pleasant, with obvious subjective value, and proven benefit for anxiety and depression … but no other clear biological or medical effects. Most notably, the evidence that massage can help back and neck pain is sketchy, and there is no reason to believe that massage can help much with any other common musculoskeletal pain problem.

Training and certification standards for massage therapists are all over the map, and most practitioners have barely scratched the surface of musculoskeletal medicine. The profession is rife with pseudoscience like crank theories about the causes of pain, the myth that massage detoxifies, or that painfully “deep tissue” massage is needed to “release” tissues (which is stressful or even harmful for many patients).

And yet some medical benefits are plausible despite the lack of evidence. For instance, many apparently successful treatments may be due to the effects of pressure on “muscle knots,” which are a likely factor in many common pain problems, but poorly understood (and difficult to treat). And regardless, the effects on mood and mental health are so profound that patients can’t really lose — it’s a valuable service whether it “works” for pain or not.

  A review of the science of massage therapy … such as it is
updated   Jul 2, 21Jul '21 22,000
Opioids for Chronic Aches & Pains+

The infamous opioids are drugs like codeine (found in small doses in Tylenol IIs and IIIs) and the more potent “hillbilly heroin” drugs like Oxycontin, Percocet, and Vicodin. They induce deep relaxation and euphoria and have the potential to make you not care about pain. Unfortunately, not caring is not a cure and their efficacy is surprisingly dubious. Some people are even genetically immune to them. They do not work well at all for chronic musculoskeletal pain (non-cancer pain), and may even backfire and cause pain. They aren’t even as effective for acute pain as they are supposed to be.

And, of course, they also have grim risks like life-altering addiction and death by overdose, which is shockingly common. The danger can’t be overstated: more ordinary Americans have started to die from opioid overdose than car accidents. The CDC declared in early 2016 that opioids should not be an option for chronic musculoskeletal pain: there’s too much danger, and too little evidence of benefit.

On the other hand, not everyone gets addicted and some people get real relief, so despite “the opioid crisis” — which is all-too real — there’s plenty of grey area here. If you have a good relationship with a cautious doctor who respects the risks, it can be reasonable to consider a short term opioid experiment: it could provide some much needed relief, and maybe even break a vicious cycle. But the need for caution and medical supervision is as high as it gets.

  The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids for musculoskeletal problems like neck and back pain
updated   Jun 30, 21Jun '21 4,750
The Complete Guide to IT Band Syndrome+

ITBS is an infamously stubborn lateral knee pain common in runners. Therapy hasn’t been working? You’re not alone. This exhaustively researched tutorial shows that most medical “facts” about the condition are wrong — supported by 224 footnotes analyzing as much of the science as you can stand. Cures cannot be guaranteed, but this tutorial offers both patients and pros 29 detailed treatment options and more insights than you can find anywhere else, as well as a free bonus: PainScience.com’s valuable trigger point tutorial.

  An extremely detailed guide to iliotibial band syndrome (runner’s knee), with detailed reviews of every treatment option
updated   Jun 25, 21Jun '21 89,000
Complete Guide to Plantar Fasciitis+

Plantar fasciitis is a stubborn pain in the arch of the foot. Yet scientists have proven that certain treatments are effective for most patients — so why don’t more professionals recommend them? Much of the science is new, and old myths die hard. This tutorial debunks the myths and reviews of all the common treatment options. Incredibly detailed, 59 sections in all, and thoroughly referenced.

  An extremely detailed guide to plantar fasciitis, especially every possible treatment option, and all supported by recent scientific research
updated   Jun 24, 21Jun '21 70,000
Does Acupuncture Work for Pain?+

Acupuncture is the poster child of alternative medicine: charismatically exotic but less absurd than homeopathy, and heavily researched, people assume there “must be something to it,” including many skeptics until surprisingly recently. But acupuncture gets its support only from junky science, while all the good tests show that it’s no better than a placebo, for pain or anything else. This has been conceded even by many acupuncture researchers (although they bizarrely try to spin it as good news). Even NCCAM admits that acupuncture “works no better than a sham treatment at easing symptoms like pain and fatigue.”

We shouldn’t be surprised: acupuncture’s popularity comes from easily debunked myths and propaganda, and it’s based on “vitalism,” a naive belief in an undetectable energy system in biology (like the Force, from Star Wars). It is not based on ancient Chinese wisdom, but a surprisingly modern invention (not that Chinese medicine was never “wise” to begin with: it’s a patchwork of superstition, habit, and guess work). Acupuncture is not and never has been used for anaesthesia (journalist James Reston did not, by his own account, contrary to legend); its use for that purpose was grossly exaggerated for political reasons during the Cultural Revolution. Finally, acupuncture isn’t even safe: aseptic technique (disinfectant, gloves) is often poor, and infections can and do happen.

Acupuncture’s glory days are over. It is supported only by ideologues and the uninformed. More study is not needed.

  A review of modern acupuncture evidence and myths, focused on treatment of back pain & other common chronic pains
updated   Jun 24, 21Jun '21 10,000
Vitamins, Minerals & Supplements for Pain & Healing+

Many nutritional supplements, vitamins, and minerals, are taken like drugs as a treatment for muscles and joints and aches and pains: the “nutraceuticals,” like glucosamine, creatine, curcumin, protein powders, and several others. Most are considered either anti-inflammatory and/or something that promotes tissue repair/growth. But most make little sense as pain treatments even in principle, and supplement science in general has been extremely disappointing and even ominous, due to the discovery of risks and serious problems with quality control in a virtually unregulated industry that is just as profitable as “Big Pharma,” and more corrupt by many measures (even just on the basis of the massive involvement multi-level marketing, a fundamentally fraudulent business model).

Glucosamine (taken mainly for arthritis) is the most popular supplement, and has been slammed by multiple large and decisively negative trials. Creatine is actually effective, but mainly for muscle fatigue resistance for intense weightlifting — probably irrelevant to pain. There are some rays of hope for Vitamin D, magnesium, curcumin, and omega-3 fatty acids. But there isn’t one single supplement that is clearly beneficial for any common kind of pain. But I explore the science and the safety of every popular option, and some more obscure ones too.

  Critical analysis of most popular “nutraceuticals” — food-like pseudo-medicines taken for medicinal purposes, especially glucosamine and creatine, mostly as they relate to pain, arthritis, and recovery from exercise and injury
updated   Jun 23, 21Jun '21 16,000
Complete Guide to Frozen Shoulder+

Frozen shoulder (adhesive capsulitis) is a common, disabling, painful loss of shoulder movement. The “adhesive” description is standard but wrong: the fibrous capsule doesn’t get stuck, but rather shrinks and thickens, a contracture. The cause of this is a mystery, but intriguingly it happens to people with diabetes much more. It can also be triggered by immobility, an underuse injury (instead of the much more common overuse injury). The joint is clearly mechanically stuck in many patients, but it’s also possible it gets neurologically shut down.

Fortunately, frozen shoulders usually thaw, but it can take months, years, or even be permanent.

Although usually easy to diagnose, frozen shoulder does often get confused with other conditions.

Treatment is difficult and varies with the stage of the condition. The usual non-surgical treatments include pain-killers and steroid (oral or injected), exercise, and “forcing the issue” with manipulations. Massage may be helpful in some cases, and there’s some hope that anti-inflammatory nutrition might be useful. Surgical options include ripping or cutting the adhesions, but only make sense for the worst cases.

  An extremely detailed science-based guide to one of the strangest of all common musculoskeletal problems, for both patients and pros
updated   Jun 17, 21Jun '21 51,000
Complete Guide to Frozen Shoulder+

Frozen shoulder (adhesive capsulitis) is a common, disabling, painful loss of shoulder movement. The “adhesive” description is standard but wrong: the fibrous capsule doesn’t get stuck, but rather shrinks and thickens, a contracture. The cause of this is a mystery, but intriguingly it happens to people with diabetes much more. It can also be triggered by immobility, an underuse injury (instead of the much more common overuse injury). The joint is clearly mechanically stuck in many patients, but it’s also possible it gets neurologically shut down.

Fortunately, frozen shoulders usually thaw, but it can take months, years, or even be permanent.

Although usually easy to diagnose, frozen shoulder does often get confused with other conditions.

Treatment is difficult and varies with the stage of the condition. The usual non-surgical treatments include pain-killers and steroid (oral or injected), exercise, and “forcing the issue” with manipulations. Massage may be helpful in some cases, and there’s some hope that anti-inflammatory nutrition might be useful. Surgical options include ripping or cutting the adhesions, but only make sense for the worst cases.

  An extremely detailed science-based guide to one of the strangest of all common musculoskeletal problems, for both patients and pros
updated   Jun 17, 21Jun '21 51,000
Neurodynamic Stretching   Stretching and stimulating nerves to treat neuropathy… hopefully new   Jun 10, 21Jun '21 2,400
Knee Replacement Surgery Doubts   Is it legit? Knee replacement is extremely popular, but not yet based on good evidence of efficacy updated   Jun 8, 21Jun '21 2,100
Marijuana for Pain+Marijuana is allegedly a medicine, widely believed to have many health benefits, but especially pain relief. As legalization spreads around the world like a wildfire, so does the hype, racing far ahead of the science — which is amazingly incomplete and extremely complex and contradictory. CBD for pain has barely been studied at all, and THC is probably more of a pain-coping drug than a pain-killing drug, due to its psychoactive effects. Despite its reputation for being completely safe, it’s not (nothing with any power can be): addiction and withdrawal, overdose, psychosis, and a bizarre vomitting syndrome are all legitimate concerns.   The hype versus the science! What does the evidence actually show about cannabis and chronic pain? new   Jun 2, 21Jun '21 6,000
The Dubious Science of Kinesiology Tape+

Therapeutic taping (Kinesio Tape® and several newer competitors) grew out of traditional compression bandaging, got commercialized as a chiropractor’s invention in the 70s, and then exploded in popularity with the innovation of colour at the 2012 Olympics. The hype machine churned out spin-off products, and many dubious claims about therapeutic benefits like injury prevention and performance enhancement. All the attention inspired a lot of research, and so we now know for sure what seemed obvious to many all along: it’s all much ado about nothing. Taping certainly doesn’t increase circulation, enhance performance, promote injury recovery, reduce inflammation, or provide meaningful support. At best it’s just a bit of minor sensory tinkering with trivial, inconsistent pain relief benefits. That’s fine as far as it goes, but consider not feeding your money to a hype machine — it’s not worth it.

  The origin story and science of therapy tapes like Kinesio Tape, KT Tape, Spider-Tech, RockTape
updated   May 24, 21May '21 4,750
Does Massage Increase Circulation?+

Massage therapy supposedly “increases circulation,” and this is one of the main mechanisms of helping patients. Although massage probably does sometimes modestly boost circulation in some ways, the scientific evidence shows that it’s too little to matter. Most importantly, light exercise is clearly a much stronger driver of circulation. Because the circulatory system is closed and blood volume is constant, circulation can only “increase” in an area at the expense of another. Also, the relaxation that we expect from any decent massage actually shunts blood into the core, away from the muscles, a robust effect that likely dominates the equation.

Blood clots broken loose by massage will be swept downstream by the circulation until they finally get trapped by the filter of the lungs, with symptoms ranging from trivial to deadly: a kind of circulatory effect, with vital safety implications. Serious examples are rare, but “minor” lung damage may be disturbingly under-reported. Clots mostly form in the calves (deep vein thrombosis), and so calf massage for a higher-risk person is like playing Russian roulette. Notably, COVID has increased clotting risks in huge numbers of people.

  Probably not, and definitely not as much as a little exercise
updated   May 10, 21May '21 11,000
Massage Therapy Side Effects+

Massage therapy is quite safe, but nothing’s perfect. Strong, deep tissue massage causes the most trouble, of course. It may aggravate problems, instead of helping. Some chronic pain patients may be disastrously traumatized by intense massage (what I call a “sensory injury”). Occasionally it causes new physical injuries, usually just minor bruises and nerve lesions, but sometimes worse: there’s a small but serious risk of spinal injury or stroke with any neck manipulation, and blood clots can be dangerously dislodged causing pulmonary embolism (a “stroke” in the lung).

On the milder side, patients often feel sore and a bit icky after massage (post-massage soreness and malaise). Although often rationalized by massage therapists as a healing crisis or the effects of “detoxifying,” it’s probably a minor muscle crush injury (rhabdomyolysis).

Athletic performance may be slightly impaired by pre-event massage — a minor consideration for most of us, but not for serious competitors.

Finally, sometimes massage therapy is a costly distraction from more appropriate care (as with any alternative medicine).

  What could possibly go wrong with massage? The risks and side effects of massage therapy are usually mild, but “deep tissue” massage can cause trouble
updated   May 10, 21May '21 5,000
Vibration Therapies, from Massage Guns to Jacuzzis   What are the medical benefits of vibrating massage and other kinds of tissue jiggling? updated   May 7, 21May '21 4,750
Modality Empires+

“Modality empire” is my own term for an ego-driven proprietary method or mode of manual therapy — a sub-discipline — championed and promoted by a single charismatic entrepreneur. Most of the “emperors” have healer syndrome, lack humility, make big promises, and make their money from unusually expensive therapy, workshops and books. Professionals are sold on the opportunity to purchase credibility in the form of increasing “levels” of certification, but the quality of these certifications is completely unregulated and often dubious. A modality empire is as much a business model as a method of helping people, and many are quite unoriginal, just branding old ideas for a new generation of workshop consumers. Obviously there is a lot of overlap between modality empires and quackery, but (just as obviously) they aren’t all bad.

  The trouble with the toxic tradition of ego-driven, trademarked treatment methods in massage therapy, chiropractic, and physiotherapy
updated   May 6, 21May '21 2,750
Anxiety & Chronic Pain   A self-help guide for people who worry and hurt updated   May 4, 21May '21 17,000
Quite a Stretch+

Stretching does not deserve its popularity and should not be considered a pillar of fitness. It does feel good, of course, and it will increase flexibility — mainly by increasing sensory tolerance rather than actually changing tissue. But flexibility is an overrated goal, and also easily achieved with other kinds of exercise that are much more beneficial for fitness in other ways (e.g. end-range strengthening).

No other significant benefit to stretching has ever been proven, not using any method, no matter how allegedly “advanced.” Almost everything people expect from it simply doesn’t work: stretch doesn’t warm anyone up, prevent soreness or injury, contribute meaninfully to rehab, or enhance peformance. In fact, it can cause injury, and impair performance! Not seriously, but still.

Regardless of efficacy, stretching is inefficient, “proper” technique is controversial at best, and many key muscles are actually biomechanically impossible to stretch in any case — like most of the quadriceps group (which runners never believe without diagrams).

Finally, despite the fact that it feels so good, stretching does not seem to constitute any kind of a treatment for common kinds of aches and pains. It falls especially flat where expectations are highest: it isn’t an effective therapy for back pain.

  Stretching science has shown that this extremely popular form of exercise has almost no measurable benefits
updated   May 3, 21May '21 32,000
Trigger Point Doubts+

People often experience acutely sensitive, aching spots in their muscle tissue that we call “muscle knots.” They can be surprisingly severe, and massaging them often seems to help quite a bit. What’s going on? The dominant theory is that a trigger point is a patch of tightly contracted muscle, an isolated spasm affecting just a small patch of muscle tissue. Unfortunately, after a few decades it’s still just a theory, and trigger point science is a bit half-baked and somewhat controversial. It’s not even clear that there is really a problem in the meat at all; it could be a sensory “disturbance,” for instance. Meanwhile, people keep hurting, and there is little doubt that there is an important, almost epidemic phenomenon here in need of explaining and treating. Massage — especially self-massage — remains a safe, cheap way of trying to deal with it, and there is some evidence that it can provide some meaningful relief (e.g. Furlan 2008 is probably the best example). That’s why I have a large tutorial devoted to how to self-treat “trigger points” — whatever they really are. But it’s important to keep in mind that they are not well understood.

  Do muscle knots exist? Exploring controversies about the existence and nature of so-called “trigger points” and myofascial pain syndrome
updated   Apr 29, 21Apr '21 15,000
The Respiration Connection   How dysfunctional breathing might be a root cause of a variety of common upper body pain problems and injuries updated   Apr 28, 21Apr '21 9,500
The Functional Movement Screen (FMS)+The Functional Movement Screen (FMS) is a set of seven physical tests of coordination and strength, especially “core” strength, invented in 1997 and now in widespread use around the world. It was originally proposed as a trouble-detection system, which is baked into the name: it’s a “screen.” Its use in the wild seems to over-reach this stated purpose.   The benefits of the popular screening system for athletes might be over-sold by some professionals   Apr 14, 21Apr '21 5,000
Pseudo-Quackery in the Treatment of Pain+Not all quackery is obvious — not even to skeptics. “Pseudo-quackery” appears to be mainstream, advanced, technological, “science-y,” or otherwise legit — quackery without any sign of being way out in left field. It has enough superficial plausibility to persist in the absence of evidence against it. This subtler type of snake oil is a more serious problem in musculoskeletal health care, because it hides right in the mainstream. For instance, it’s nearly synonymous with the early history of physical therapy, and remains alarmingly prevalent in that profession. So pseudo-quackery is extremely common, and generates more false hopes and wasted time, energy, money, and harm than more overt quackery, which is relatively marginalized.   The large, dangerous grey zone between evidence-based care and overt quackery in musculoskeletal and pain medicine   Mar 24, 21Mar '21 4,250
A Deep Dive into Delayed-Onset Muscle Soreness+

Delayed Onset Muscle Soreness (DOMS), AKA “muscle fever,” is the muscle pain and weakness that starts up to a day after unfamiliar exercise, peaking up to two days later. The strongest trigger is a lot of eccentric contraction (e.g. quadriceps while descending). DOMS is much weaker after the next workout, but the first bout can be so fierce that people avoid starting valuable exercise programs, especially strength training. It’s worse for some people due to genetic factors and other biological stresses (especially sleep trouble).

Medical science can’t explain DOMS, let alone treat it. Many athletes believe that massage helps, but that’s not what the evidence shows. And many take ibuprofen as prevention, but that doesn’t work either. Drugs will only take the edge off the pain. The only promising treatments are heat and Indian food (curcumin), but not confirmed. Excessive DOMS may also be a symptom of other health problems, some of which can be treated, most notably vitamin D deficiency and insomnia.

DOMS is probably not caused by micro-trauma — a popular old idea — although it might be a mild form of “rhabdomyolysis,” which is caused by mucle proteins spilling into the blood. Some kind of “metabolic stress” may be a more likely culprit, and yet there is no clear link between DOMS and any specific biological marker (and definitely not lactic acid). There are even clues that DOMS is neurological. Certainly it is not straightforwardly inflammatory: evidence suggests that inflammation is what reduces DOMS pain as you continue to exercise. Mysterious indeed!

  The biology & treatment of “muscle fever,” the deep muscle soreness that surges 24-48 hours after an unfamiliar workout intensity
  Mar 19, 21Mar '21 15,000
The Chiropractic Controversies+

The chiropractic profession has a long history of scientific and ethical controversies swirling around it. Why is chiropractic perpetually contentious?

  • Aggressive marketing, especially unethical pre-paid treatment packages and other forms of over-treatment, even of children and babies.
  • The original “big idea” of chiropractic, still alive and well, is that nearly any health problem can be cured by spinal manipulation — an extravagantly too-good-to-be-true promise.
  • Doubts about the efficacy of treating even just ordinary neck and back pain, plus particularly serious concerns about the safety of neck manipulation.

Many chiropractors share these concerns. The profession is strongly divided between progressives and traditionalists — and it’s hard for patients to know which is which. But at the centre of all the controversy is a service that many people are happy to pay for: a spinal joint “pop” can be super satisfying, like “scratching an itch you can’t reach.” Whatever explains this and whether its medically meaningful or not, I believe it’s the true source of chiropractic’s viability as a business.

  An introduction to chiropractic controversies like aggressive billing, treating kids, and neck manipulation risks
  Mar 17, 21Mar '21 9,000
Tennis Elbow Guide+Tennis elbow is a classic but surprisingly mysterious repetitive strain injury to the muscles and tendons on the back of the arm and outside of the elbow, the wrist and finger extensors. This detailed guide explores the nature of the beast and reviews all treatment options.   Not just for tennis players! A detailed, science-based tour of the nature of the beast and reviews of all the treatment options   Mar 16, 21Mar '21 14,000
Nerve Pain Is Overdiagnosed   Our cultural fear of neuropathy, and a story about nerve pain that wasn’t   Mar 11, 21Mar '21 1,900
Voltaren Gel: Does It Work?+

Voltaren® Gel (topical diclofenac) is a particularly safe and useful medicine. It’s an anti-inflammatory cream, so it can be applied only where you need it, instead of soaking your entire system with a medication, avoiding or dramatically reducing common side effects like indigestion, as well as some serious safety concerns associated with oral diclofenac. In the US, this drug is FDA-approved to treat osteoarthritis in “joints amenable to topical treatment, such as the knees and those of the hands,” but it probably also works for some other painful problems, such as some repetitive strain injuries and back pain. The evidence shows that it “provides clinically meaningful analgesia.” So this product actually works and gets a pass from skeptics and critics — a rare thing in the world of pain treatments!

Other topical analgesics are a mixed bag. The salicylates are likely effective but have more safety concerns (salicylate poisoning isn’t rare). The spicy-hot creams (Tiger Balm etc) won’t work miracles but may have some surprisingly benefits. Arnica creams are largely useless, especially the homeopathic preparations.

  The science of the topical pain-killers, which can be effective without dosing your entire system
  Feb 23, 21Feb '21 5,500
The Tyranny of Yoga, Meditation, and Mindfulness   Do you really need to try them? How much do they matter for recovery from conditions like low back pain?   Feb 3, 21Feb '21 4,500
Shin Splints Treatment, The Complete Guide+

Do you know why your shins hurt? Shin splints are often not what they seem. With several possible underlying problems, patients often end up barking up the wrong tree. There are four very different types of shin pain. This tutorial breaks it down for you and goes through all the treatment options and recent science. About 20 times more information about shin splints in one place than you can get anywhere else. Comes with a free copy of PainScience.com’s trigger point tutorial!

  An extremely detailed guide to all types of shin splints for both patients and professionals, including thorough reviews of every possible treatment option, and all about the nature of the beast
  Jan 20, 21Jan '21 43,000
Cognitive Behavioural Therapy for Chronic Pain   The science of CBT and other psychotherapies for chronic pain.   Jan 15, 21Jan '21 2,400
Missing Serious Symptoms+

Ominous signs and symptoms of serious disease are often overlooked, misinterpreted, and minimized by practitioners of alternative medicine. Partients invest time and money in red herrings, distracted from better diagnostic and therapeutic options (a high “opportunity cost”). The consequences are most tragic when minor problems are missed until they become serious. Most misdiagnosis in alt-med is caused by simple ignorance and preoccupation with pseudoscientific pet theories about disease, but the failure is often more ideological in nature, due to militant dismissal of important precepts of scientific medicine (e.g. germ theory denial). Doctors also overlook problems, of course — nobody’s perfect (see Medical Errors in Perspective). But the chances of a doctor missing a dangerous disease are much lower, because they have far more experience with much sicker people (see Chiropractor, Naturopath Training Way Less Than Doctors).

  Alternative medicine often diagnoses overconfidently while overlooking or underestimating serious symptoms
  Jan 15, 21Jan '21 1,300
Reviews of Pain Professions   An opinionated guide to the most popular sources of professional help for injuries and chronic pain   Dec 29, 20Dec '20 9,500
The “Impress Me” Test+It is common for those who promote dubious therapies and treatments to claim scientific support based on studies that were technically positive — but when you look at the data you only find evidence of a trivial beneficial effect. The evidence may be slightly positive, but it fails to impress. The treatment is damned with faint praise.   Most controversial therapies are fighting over scraps of “positive” evidence that damn them with faint praise   Dec 13, 20Dec '20 2,500
Sensitization in Chronic Pain+Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. This is called “central sensitization.” (And there’s peripheral sensitization too.) Sensitized patients are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.   Pain itself can change how pain works, resulting in more pain with less provocation   Nov 27, 20Nov '20 7,500
What Happened To My Barber?   Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers   Nov 23, 20Nov '20 4,000
When to Worry About Low Back Pain+

The pain of back pain usually makes it seem worse than it is. The most worrisome kinds of back pain rarely involve severe pain, and many common problems (like slipped discs) are mostly much less serious than people fear. Only about 1% of back pain is ominous, and even then it’s often still treatable. Most of that 1% is cancer, autoimmune disease, and spinal cord damage.

Don’t medically investigate back pain until it’s met at least three criteria: (1) it’s been bothering you for more than about 6 weeks; (2) it’s severe and/or not improving, or actually getting worse; and (3) there’s at least one other “red flag”: age over 55 or under 20, painful to light tapping, fever/malaise, weight loss, slow urination, incontinence, groin numbness, a dragging toe, or symptoms in both legs like numbness and/or tingling and/or weakness. Note that signs of arthritis are not red flags.

Red flags do not confirm that something horrible is going on, just that it’s time to talk to a doctor. And the absence of red flags is not remotely a guarantee that you’re in the clear — but it’s a good start.

  And when not to! What’s bark and what’s bite? Checklists and red flags and non-scary possible explanations for alarmingly back pain
  Nov 12, 20Nov '20 5,000
Does Epsom Salt Work?+

Epsom salt (magnesium sulfate) in your bath is cheap and harmless and it makes the water feel “silkier,” but it probably doesn’t do anything else you hope it’s doing. Contrary to popular belief, it probably has no significant benefits for most common kinds of aches and pains. Oral magnesium supplementation may be helpful for some types of chronic pain for some people (with magnesium deficiency), and it probably works much better than trying to soak in it. Topical delivery via creams is scientifically controversial, and absorption from baths is virtually unstudied: it may not work in a bath at all, or only modestly and erratically. For pain, the soothing heat of a nice bath is probably far more therapeutic than whatever magnesium might be absorbed. Bathing in a magnesium sulfate solution also has no other known medical benefits other than treating skin infections. Most theories you hear about how Epsom salt baths work are oversimplified and meaningless (for instance, nearly everyone says it is absorbed by osmosis, which is definitely wrong). The case for the healing powers of Epsom salt is mostly made by people selling the stuff, or recommending it as carelessly as an old wives’ tale. If relatively dilute home salt baths were actually medicinal, then far more concentrated sources like The Dead Sea would have clear health effects, which they definitely do not.

  The science and mythology of Epsom salt bathing for recovery from muscle pain, soreness, or injury
  Nov 11, 20Nov '20 19,000
Chronic, Subtle, Systemic Inflammation+

Chronic, subtle, systemic inflammation may be a factor in stubborn musculoskeletal pain and arthritis. We get more inflamed as we age, a process quaintly known as “inflammaging” (for real). That trend correlates with poor fitness and obesity (metabolic syndrome, the biological precursor to diabetes and heart disease). And that, in turn is linked to chronic psychological stress, and of course biological stresses like smoking and sleep deprivation. Basically, the “harder” we live, the more likely inflammaging and metabolic syndrome get.

It’s unclear whether metabolic syndrome is inflammatory, or inflammation causes metabolic syndrome, and there are several other unproven but plausible reasons why inflammation escalates as we age, such as the accumulation of permanent minor infections, lasting collateral damage from past infections (essentially autoimmune disease and allergies that are too subtle or nonspecific to diagnose), and environmental poisons.

Systemic inflammation cannot be diagnosed or treated reliably by any means: it is simply too complicated and mysterious. It could have seven different causes, most of them untreatable even if you could confirm them. Nevertheless, it is a trendy bogeyman, and there are lots of popular, over-hyped ideas about how to treat it, especially “anti-inflammatory diets.” For chronic pain patients, such methods may be worth trying, but it’s important to understand that they are far from proven. Probably the best defense against inflammation is simply to be as fit and healthy as possible.

  One possible sneaky cause of puzzling chronic pain
  Nov 8, 20Nov '20 9,500
Poisoned by Massage+

Sometimes we feel a bit cruddy and sore after a massage, like it was a big workout. Post-massage soreness and malaise (PMSM) is embraced as a minor side effect and hand-waved away by almost everyone as some kind of no-pain-no-gain thing. But it can be much harsher.

Massage is not “detoxifying” in any way (that’s pseudoscientific nonsense). Ironically, it may be the opposite: PMSM is may be caused by mild rhabdomyolysis, a type of poisoning. True rhabdo is a medical emergency in which the kidneys are gummed up by myoglobin from crushed muscle. But tamer rhabdo can be caused by physical stress, even just intense exercise (medical reality, see exertional or “white collar” rhabdo)…and quite possibly “deep tissue” massage as well, which is still just a hypothesis.

But that hypothesis is getting more evidence-based as evidence accumulates. There are three good formal case studies now (Lai, Tanriover, Chen), and I have many informal ones too: many people find this article and send me reports of post-massage rhabdo signs/symptoms. The phenomenon of PMSM needs explaining, and rhabdo is surprisingly good candidate. There is plenty of plausibility and empirical “smoke” to support the hypothesis.

And what if it’s true? A major side effect, totally at odds with faith in the value of strong massage.

Mild PMSM also has several possible non-rhabdo explanations, like coincidental mild illness, pathological vulnerability, and psychologically disarming our normal psychological defenses. (A Jarisch-Herxheimer reaction is not a plausible explanation.)

And you can’t “flush” the rhabdo (or anything else) away with massage or by drinking a little extra water.

  Rather than being DE-toxifying, deep tissue massage may actually cause a toxic situation
  Nov 8, 20Nov '20 9,000
Insomnia Until it Hurts+Almost everyone needs to take sleep deprivation more seriously. We are used to thinking of insomnia as a symptom, but it can also be hazardous in itself in many ways. Chronic pain is probably aggravated by insomnia or even mild but chronic sleep deprivation.   The role of sleep deprivation in chronic pain, especially muscle pain   Oct 28, 20Oct '20 4,500
13 Kinds of Bogus Citations   Classic ways to self-servingly screw up references to science, like “the sneaky reach” or “the uncheckable”   Oct 19, 20Oct '20 5,500
The False Humility of “Facilitating” Healing+

The idea of facilitating self-healing is a cliché of alternative medicine. For example: “A healer just triggers your own ability to heal yourself.” It’s sacharine, silly, inspirational-poster nonsense. More technically, it’s a “deepity,” an idea that is either profound but wrong, or true but trivial. If healing actually could be “facilitated,” that would be miraculous.

Facilitated healing is touted to make someone seem like a “healer” without coming right out and saying it, a “humblebrag.” It sounds humble, but it isn’t. It also rationalizes therapy that does not have a clear or specific mechanism.

  Facilitating self-healing is either real but trivial, or interesting but wrong.
  Oct 9, 20Oct '20 1,100
Chronic Pain and Inequality   The role of racism, sexism, queerphobia, and poverty in health and chronic pain   Oct 6, 20Oct '20 3,000
Vulnerability to Chronic Pain+

The specific cause of chronic pain are often less important than non-specific sensitivity to any pain. The biggest risk factors for pain chronicity are things like poor health, fitness, and socioeconomic status, inequality… and they overshadow common scapegoats like poor posture, spinal degeneration, or even repetitive strain injury.

How can nothing in particular make us hurt? Because pain is weird, a generally oversensitive alarm system that can produce false alarms even at the best of times, and more of them when your system is under strain.

So what are these non-specific vulnerabilities to chronic pain, specifically? Sleep deprivation is one of the most obvious examples: everything hurts more when you lose too much sleep. Other examples: smoking, too much booze, sedentariness, stress, and much more.

And what can you do about this? “Easy”: just get healthier! With a variety of vulnerability reduction projects, AKA “lifestyle medicine.” So not actually easy at all, but simple in principle.

Getting more exercise and sleep are usually the lowest hanging fruit. Quitting bad habits like smoking, drinking, and junk food are harder but simple and very effective. In some cases, loneliness can be almost easy to fix (join a club).

Where’s the science? Does this work? No one knows. It’s plausible and likely. But you really cannot waste your time trying to be a healthier, fitter person!

  Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems
  Oct 2, 20Oct '20 5,000
Smoking and Chronic Pain   We often underestimate the power of (tobacco) smoking to make things hurt more and longer   Sep 30, 20Sep '20 1,300
Sports Injury Prevention Tips   A few evidence-based ways to reduce your risk of injury   Sep 24, 20Sep '20 3,750
When to Worry About Neck Pain … and when not to!+

The most worrisome kinds of neck pain rarely involve severe pain, and common problems like slipped discs are usually much less serious than people fear. Sharp and stabbing pains are usually false alarms. Only about 1% of neck pain is ominous, and even then it’s often still treatable. Most of that 1% is cancer, autoimmune disease, and spinal cord damage.

Don’t medically investigate neck pain until it’s met at least three criteria: (1) bothering you for more than about 6 weeks; (2) severe and/or not improving, or actually getting worse; and (3) at least one other “red flag”: age over 55 or under 20, painful to light tapping, fever/malaise/nausea, weight loss, nasty headache, severe stiffness, very distinctive pain, and numbness and/or tingling and/or weakness anywhere else. Note that signs of arthritis are not red flags.

Red flags do not confirm that something horrible is going on, just that it’s time to talk to a doctor. And the absence of red flags is not remotely a guarantee that you’re in the clear — but it’s a good start.

  Tips, checklists, and non-scary possible explanations for terrible neck pain
  Sep 5, 20Sep '20 4,750
A Guide to Sciatica Treatment for Patients+There are several ways to have sciatica, a symptom of shooting pain in the buttock and down the back of the leg with many possible causes (not just sciatic nerve irritation). Worrisome causes are rare, but do exist.   A guide to buttock and leg pain (which may or may not involve the sciatic nerve)   Aug 31, 20Aug '20 8,000
6 Main Causes of Morning Back Pain+

Most morning back pain is probably caused by low-grade inflammation which ramps up with age (“inflammaging”) and is notoriously worse at the start of the day. This common issue can be hard to distinguish from its much rarer cousin, full-blown “inflammatory back pain,” which is more likely to actually wake you up.

Other usual suspects include vitamin D deficiency, garden variety muscle pain, fibromyalgia, tissue stress from awkward sleeping postures, and — of course — just poor quality sleep.

Nocturnal disc swelling often gets the blame for morning back pain, but it shouldn’t— it’s too speculative. And morning back pain is probably never psychosomatic.

Fighting inflammation is simple but not easy: it’s mainly about being as fit and healthy as possible, which includes almost any lifestyle medicine approach, such as a heart-healthy diet (including perhaps fasting), reducing anxiety, better sleep, and avoidance of exercise and metabolic extremes.

Vitamin D deficiency is easy to test for and fix, of course. Muscle pain treatment can be much more complex — both an opportunity and a challenge — but may also yield to simple massage techniques and heat. And improving sleep posture is probably the least valuable and most tricky, but it’s worth doing your best to stay in a “neutral” position, and particularly avoiding face down sleeping. There is no ideal mattress for back pain except, maybe, just a good quality new one. “Sleep breaks” may also be a helpful trick.

  Why is back pain worst first thing in the morning, and what can you do about it?
  Aug 29, 20Aug '20 9,500
💩 Massage Therapists Say   A compilation of more than 50 examples of the bizarre nonsense spoken by massage therapists with delusions of medical knowledge   Aug 27, 20Aug '20 11,000
Electromagnetic Sensitivity Absurdity+

Electrosensitivity is an alleged allergy to electromagnetic fields and radiation. It is the basis for paranoia particularly about the health effects of Wi-Fi networks, power lines, and cell phones — fears that top the charts of human irrationality. There’s little doubt that the afflicted are suffering from something, but it is either an unrelated medical condition and/or psychosomatic. Electrosensitivity has been thoroughly debunked.

Unsurprisingly, many people who believe they can heal with life energy — reiki, acupuncture, and so on — are also active spreading fear, uncertainty, and doubt about artificial energy.

No one with an actual energy allergy would last a day anywhere in the modern world. It would be an electrosensitive holocaust. They’d vanish in a poof of oversensitive smoke, moths flying into a bonfire.

  Electrosensitivity is an imaginary, debunked energy allergy
  Jul 24, 20Jul '20 1,200
Plantar Fasciitis Patients Have Thick Soles   There’s a connection between plantar fasciitis and a surprisingly thick tissue in the arch of the foot   Jul 14, 20Jul '20 1,200
Heat for Pain and Rehab+

Heat therapy is relaxing and a mild pain reliever, safer than any pain-killing drug and possibly as effective in some cases. Although far from proven or miraculous, it can probably take the edge off several kinds of pain, mostly duller and persistent pains associated with stiffness, cramping, and neuropathic sensitivity. It probably works simply because it’s comforting (which is applied neurology, more like triggering a reflex than a psychological effect).

But heat will worsen some conditions much worse: please do not use heat on obviously injured or infected tissue (puffy, red, and/or hot). The difference between a minor injury and a bad “muscle knot” can be subtle, but heat is bad for one and nice for the other. Back pain is often ambiguous in this way! Experiment cautiously.

Tiger Balm and similar products are “spicy,” not warm, and are only mildly useful (via a different mechanism, neurological “distraction”).

  A detailed guide to using heat as therapy for acute and chronic pain and recovery from injury
  Jul 10, 20Jul '20 6,500
Vitamin D for Pain+

Walk down a busy street in Canada, Russia, or the UK — high-latitude countries — and you’ll pass someone with vitamin D deficiency every few seconds. D deficiency is certainly real and common (but probably not as extreme as some experts believe). But how much does it matter?

There’s a lot of hype about vitamin D, but most of the controversy is about healthy patients. People with actual health problems are a different kettle of fish, and chronic pain specifically is a particularly special case. Vitamin D deficiency is suspiciously common in people with chronic pain, maybe because it actually causes it, or at least makes it worse. Symptoms include muscle and bone aching, fatigue and weakness, sensitization, and depression.

Chronic pain is usually caused by a sinister stew of many factors that eat away at people for many years. Trying to solve it by fixing one thing, like vitamin D deficiency, is like trying to fix a broken engine with just one tool. But it might help, and the only thing worse than chronic pain with six causes is … seven causes. There’s a good case to be made for presumptive treatment of vitamin D deficiency. A lot of healthy people take this stuff “just in case”; it’s hardly radical for pain patients to give it a shot.

Supplements and sunshine should be your main sources of vitamin D. Why not just eat a D-rich diet? Because you’d have to eat a LOT of fish. It’s hard to get a meaningful amount of vitamin D from food.

Please do not take “mega” doses of vitamin D. There’s a large margin of safety with vitamin D, but megadosing is just silly (and dangerous).

  Is it safe and reasonable for chronic pain patients to take higher doses of Vitamin D? And just how high is safe?
  Jul 9, 20Jul '20 5,500
Repetitive Strain Injuries Tutorial+Repetitive strain injuries have (at least) five surprising features: (1) they aren’t exactly “inflamed” despite giving that strong impression, (2) they are mostly not caused by biomechanical failures or alignment problems, (3) even stubborn cases usually just need more rest (more specifically, savvy “load management” erring on the side of less in the short term), (4) they are routinely complicated by muscle pain, and, the weirdest of the bunch, (5) they play “head games” to a shocking degree (that is, they are profoundly modulated by the central nervous system, both psychological factors we can affect and neurological ones we can’t).   Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome   Jul 9, 20Jul '20 17,000
The Role of “Spasm” in Frozen Shoulder+

There may be two kinds of “frozen” shoulder: mostly invincible contracture and more plastic functional inhibition of shoulder mobility. I make the case for this phenomenon in detail in my frozen shoulder book. This excerpt zooms in on how you might be able to tell these two types apart.

The “freezing” of frozen shoulder is mainly caused by a contracture of the capsule (thickening and shrinking), and is extremely hard to change (maybe impossible). But in many cases that may be complicated by a more functional limitation, or even replaced by it — a limitation imposed by a “nervous” nervous system, which is more treatable than contracture.

A contractured shoulder will never allow extra movement, but an inhibited shoulder can ease temporarily in some situations, and so even a brief improvement is diagnostic. For instance, functional freezing might back off if you are deeply relaxed and you get someone else to move your shoulder for you extremely gently, or if it’s well-supported by immersion in water. Exercise is also a terrific short-term pain killer and inhibition fighter. And some drugs, like muscle relaxants and other systemic sedatives and psychoactive drugs (benzos, opioids, pot, booze), might soften the intense inhibition of the rotator cuff muscles.

Bottom line: any improvement in shoulder range, however fleeting, is impossible if it’s contractured and points to a functional limitation instead.

  How to identify cases of functional frozen shoulder, dominated by muscular inhibition
  Jun 18, 20Jun '20 1,800
Baxter’s Neuritis and Plantar Fasciitis+

Baxter’s neuritis (AKA distal tarsal tunnel syndrome) is entrapment of the first branch of the lateral plantar nerve. It’s rare overall, but probably much more common in people with stubborn heel pain. It can be considered a cause of plantar fasciitis, or just a condition that gets confused with it. It causes pain much like plantar fasciitis, but with some distinctive differences: less morning pain, more altered sensation, directly sensitive to pressure on the inside of the heel.

“Tarsal tunnel syndrome” is closely related to Baxter’s neuritis, but involves the impingement of nerves just a little higher up, on the inside of the ankle, where they pass through the tarsal tunnel.

Concerns about “nerve pain” are overblown in our society. While it seems obvious that pinching nerves will hurt, in fact they are surprisingly tolerant of physical stress (they have to be). But sometimes nerves get pinched harder, for longer, and/or the biological vulnerability is higher for some reason, and the result is peripheral neuropathy.

Baxter’s neuritis is probably a phenomenon because of the relatively vulnerable physical predicament of the lateral plantar nerve. And, as with most foot problems, the main rehab challenge is that it’s so hard to reduce physical stresses in the foot without anti-gravity technology.

We all tend to assume that entrapped nerves need to be cut free by surgery, like freeing a dolphin from a fishing net. Which can work…but doesn’t always. Conservative care first! Give it a rest, and reduce your vulnerability to neuropathy with health and fitness (lifestyle medicine).

  A rare nerve entrapment that can explain some stubborn cases of “plantar fasciitis”
  May 28, 20May '20 1,600
Why Do Muscles Feel Stiff and Tight?+

“Stiff” and “tight” are imprecise, subjective terms: they are symptoms, a kind of mild pain caused by mostly minor problems. People who feel stiff often assume their range of motion is limited, probably by literally short muscles, but this is rarely the case, despite how it feels. Causes of common stiffness include exercise soreness, “muscle knots,” overuse injuries, arthritis and “inflammaging,” inflammation (from chronic infection, autoimmune disease), by mild widespread pain (fibromyalgia), anxiety disorder, and medication side effects.

Paradoxically, even hypermobility is a major cause of the sensation of stiffness!

True abnormal muscle tightness (rigidity, spasticity) is called “dystonia,” which occurs with a variety of pathologies, like wry neck or multiple sclerosis. A lot of stiffness caused by dystonia is overshadowed by other symptoms, but some milder dystonias blend right in with other common aches and pains. Ruling out dystonia is not easy.

Stiffness is definitely linked to the phenomenon of “muscle knots” (trigger points), but these are just unexplained sore spots in soft tissue — no one knows if they cause any dystonia, but it’s unlikely.

  Maybe your range of motion is actually limited, or maybe it just feels that way
  May 13, 20May '20 5,000
When To Worry About Shortness of Breath … and When Not To+

Difficulty breathing is a common complaint and a tough diagnostic challenge, and there are some serious causes to be aware of. However, almost all non-severe cases are probably caused by minor muscle knots (trigger points), respiratory dysfunction, and/or anxiety: all of which are relatively simple and cheap problems to try to self-treat. Relief may even be surprisingly easy for some patients. It’s safe and cheap to experiment with self-massage for muscular trigger points. Although changing a bad habit is always tricky, respiratory strength training is an effective and worthwhile fitness activity in itself. And learning better anxiety management is something almost anyone can benefit from, even if it doesn’t help the breathing.

  Three minor causes of a scary symptom that might be treatable
  May 1, 20May '20 5,000
Psoas, So What?+The iliopsoas muscle (“illy-oh so-ass”) is a two-in-one hip flexing pair, mostly only palpable through the guts. Its clinical importance is often curiously exaggerated, but sometimes it does need a massage.   Massage therapy for the psoas major and iliacus (iliopsoas) muscles is not that big a deal   Apr 22, 20Apr '20 2,750
Should You Get A Lube Job for Your Arthritic Knee?   Reviewing the science of injecting artificial synovial fluid, especially for patellofemoral pain   Apr 14, 20Apr '20 1,900
Science versus Experience in Musculoskeletal Medicine   The conflict between science and clinical experience and pragmatism in the management of aches, pains, and injuries   Apr 12, 20Apr '20 4,000
“Windows of Opportunity” in Rehab+A “window of opportunity” (WOO) in therapy is a period of minor pain relief or boosted confidence that facilitates normal activity/exercise, which in turn is what delivers the true rehab value. This is exemplified in some cases of frozen shoulder. A placebo can also generate a bit of WOO, but a good WOO is a little more substantive. The idea of WOOs is also often used as a self-serving justification for ineffective methods that only produce trivial, transient benefits.   The importance of WOO in recovery from injury and chronic pain (using frozen shoulder as an major example)   Mar 18, 20Mar '20 1,700
Does barefoot running prevent injuries?   A dive into the science so far of barefoot or minimalist “natural” running   Mar 17, 20Mar '20 7,000
How to Simplify Chronic Pain Puzzles+Occam’s razor is the logical principle that simpler explanations are usually better. It’s a “razor” because it cuts away useless extra ideas. It’s the sharpest tool in my mental shed. I can hardly imagine life without it, let alone troubleshooting pain problems without it.   Use Occam’s razor to clean up a mess of theories about your stubborn injury or pain problem   Mar 10, 20Mar '20 1,500
Alternative Medicine’s Choice   What should alternative medicine be the alternative to? The alternative to cold and impersonal medicine? Or the alternative to science and reason?   Feb 27, 20Feb '20 5,000
Strength Training for Pain & Injury Rehab   Why building muscle is easier, better, and more important than you thought, and its role in recovering from injuries and chronic pain   Feb 1, 20Feb '20 9,000
Does Cartilage Regeneration Work?   A review of knee cartilage “patching” with autologous chondrocyte implantation (ACI)   Jan 28, 20Jan '20 2,750
Does Platelet-Rich Plasma Injection Work?+

Platelet-rich plasma (PRP) injections bathe troubled cells in a concentrated mixture of platelets from your own blood. Platelets are involved in clotting and wound healing, and so the more-is-better hope is that they’ll stimulate healing “naturally” — regenerative medicine, supposedly. Unfortunately, the hype and costs are high, there could be risks above and beyond the basic risks of any injection, and the science so far is completely discouraging — three major evidence reviews have ruled it “ineffective.” Although it’s plausible and interesting in theory, this stuff just can’t beat placebos in fair tests.

  An interesting treatment idea for arthritis, tendinopathy, muscle strain and more
  Jan 25, 20Jan '20 3,750
The Pressure Question in Massage Therapy+

There is no clear justification for painfully intense “deep tissue” massage, and it’s actually hazardous to many patients, but the pressure question is greatly complicated by the fascinating paradox of “good” pain, wildly varied patient pain tolerance and preferences (often timidly repressed), and popular faith in the “no pain, no gain” principle.

“Good pain” is at the heart of the pressure question: a strange, potent sensory paradox that many people actually seek out as the goal of therapy, consciously or unconciously. Either it isn’t literally painful (just intense), or it’s painful but desired anyway because of relief or belief: an actual biological relief or at least the belief that there is one. But it’s important to note that not all satisfying, relieving sensations are genuinely helpful (e.g. scratching a mosquito bite).

“Bad pain” is unpleasant but manageable and probably safe — tolerate it cautiously, to a point.

“Ugly pain” is dangerous both physically and neurologically, causing a “fight or flight” reaction — always avoid it.

People do have clear pressure preferences: they often fire massage therapists who give treatments that are too painful or too fluffy. Pressure that’s fine for you may cause severe pain, emotional distress, “sensory injury” (sensitization) in others, or even physical injury, so pressure should be customized but often isn’t. Brutal massages might be appreciated or even helpful, but most people can’t tell the difference between the kind of pain that might be a necessary part of therapy, and ugly pain that is just abusive and dangerous.

Some possible justifications for painfully intense massage (these aren’t endorsements) include the destruction of motor end plates to “de-activate” trigger points; somatoemotional release (pain often strongly “resonates” with strong emotions like grief); moving tissue fluids; or just creating a strong, novel sensory experiences (which may have many subtle benefits).

  What’s the right amount of pressure to apply to muscles in massage therapy and self-massage?
  Jan 19, 20Jan '20 6,500
Statistical Significance Abuse+The word “significant” in scientific abstracts is routinely misleading. It does not mean that the results are large or meaningful, and in fact is used to hide precisely the opposite. When only “significance” is mentioned, it almost invariably refers to the notoriously problematic “p-value,” a technically-true distraction from the more meaningful truth of a tiny “effect size”: results that are not actually impressive. This practice has been considered bad form by experts for decades, but is still extremely common.   A lot of research makes scientific evidence seem more “significant” than it is   Jan 8, 20Jan '20 4,250
Ugly Bags of Mostly Water   The chemical composition of human biology   Jan 3, 20Jan '20 2,300
Do You Believe in Qi?   How to embrace a central concept of Eastern mysticism without being a flake   Dec 19, 19Dec '19 1,300
You Might Just Be Weird+

Strange, wonderful, and problematic anatomical variations occur in humans all the time. The best anatomical diagrams depict average anatomy only. “The word ‘normal’ is probably an inappropriate word to apply to the human body” (Dr. Ian Griffiths).

The line between “normal variation” and “defect” is blurry. But do anatomical variations ever cause trouble, like chronic pain? Oh hell yes. Certainly not all, probably not most, but definitely some. We often make a fuss over the visible anatomical variations—too much of a fuss in many cases (“structuralism”)—while completely neglecting the possibility of invisible oddities that may be more important. Such cases often join the “X-files” of therapy, the unsolved clinical mysteries that every pro encounters.

“For every visible, superficial oddity, there may be an invisible internal one… and only surgeons ever find out about them” (Dr. Sherwin Nuland).

  The clinical significance of normal — and not so normal — anatomical variations
  Dec 14, 19Dec '19 4,250
The Trouble with Chairs+Inactivity and excessive sitting isn’t healthy, but probably not as bad as it’s cracked up to be, and has reassuringly little to do with back pain especially. The best chair for back pain is the most comfortable one.   The science of being sedentary and how much it does (or doesn’t) affect your health and back pain   Nov 30, 19Nov '19 9,000
Healer Syndrome+“Healer syndrome” is a common delusion of grandeur in alternative medicine, especially massage therapy, naturopathy, and chiropractic, where many afflicted professionals like to be known as “healers” with allegedly unusual curative powers, vaguely defined, pseudoscientific, or based on the exaggerated importance of a single idea. Such lack of humility is tragically common. Healer syndrome has reached its most extreme in some of the founders of methods of therapy, what I call “modality empires.”   The problem with health care professionals, especially in alternative medicine, who want to be known as “healers”   Nov 16, 19Nov '19 2,100
Organ Health Does Not Depend on Spinal Nerves!+Are the little bundles of nerves that exit your spine the wellspring of all visceral vitality? Will your organs wilt like neglected house plants if those nerve roots are slightly impinged? No: cut a nerve root completely, and you’ll certainly paralyze something, but not an organ, because organs simply don’t depend on spinal nerve roots. And yet this is what many chiropractors believe, and would like their customers to believe, after a century of contradictory evidence.   One of the key selling points for chiropractic care is the anatomically impossible premise that your spinal nerve roots are important to your general health   Nov 12, 19Nov '19 4,500
Get in the Pool for Pain   Aquatic therapy, aquajogging, water yoga, floating and other water-based treatment and injury rehab options   Nov 5, 19Nov '19 3,750
Strength Training Frequency+

Strength training is not only more beneficial for general fitness than most people realize, it isn’t even necessary to spend hours at the gym every week to get those benefits. Almost any amount of it is much better than nothing. While more effort will produce better results, the returns diminish rapidy. Just one or two half hour sessions per week can get most of the results that you’d get from two to three times that much of an investment (and that’s a deliberately conservative estimate). This is broadly true of any form of exercise, but especially so with strength training. In a world where virtually everything in health and fitness is controversial, this is actually fairly settled science.

  Less is more than enough: go to the gym less frequently but still gain strength fast enough for anyone but a bodybuilder
  Oct 24, 19Oct '19 9,500
Are Orthotics Worth It?   A consumer’s guide to the science and controversies of custom orthotics, orthopedic shoes, and other allegedly corrective foot devices   Oct 11, 19Oct '19 5,500
Don’t Worry About Lifting Technique   The importance of “lift with your legs, not your back” to prevent back pain has been exaggerated   Sep 27, 19Sep '19 3,750
Progressive Training   How to take “baby steps” to recovery from an injury or pain problem   Aug 16, 19Aug '19 3,000
Does Spinal Manipulation Work?+

The idea of “adjusting” the spine refers to many different manual therapies that wiggle, pop, and otherwise manipulate spinal joints. The umbrella term for these treatments is “spinal manipulative therapy” (SMT). Expert opinions on SMT range widely, with some experts expressing strong concern and skepticism. Its provenance in chiropractic subluxation theory is dubious, its benefits are minor at best, and yet there are serious risks, even including paralysis and death in the case of SMT for the joints of the neck.

Despite all the controversy, there has been little high quality scientific research to determine whether or not SMT is safe and really works. Major science reviews have either been thoroughly discouraging or barely encouraging. SMT can’t possibly be working any miracles.

And yet spinal joint popping in particular is something that people crave, and most clinicians believe that some forms of SMT can be helpful to some of their patients, some of the time. There seems to be almost no doubt that there is something of therapeutic interest going on in SMT, for at least some patients.

  Spinal manipulation, adjustment, and popping of the spinal joints and the subluxation theory of disease, back pain and neck pain
  Aug 9, 19Aug '19 17,000
The Art of Rest+Resting “properly” is trickier and a more critical part of injury rehabilitation than most people realize, and is often at odds with a culture tradition of aggressive therapeutic exercise (“no pain, no gain”). This article explores the rationale for resting, and tactical considerations like how to rest anatomy that you need to use for your job, and how to know how much rest is enough.   The finer points of resting strategy when recovering from injury and chronic pain (hint: it’s a bit trickier than you might think)   Aug 1, 19Aug '19 6,500
Eccentric Contraction+An eccentric or braking contraction is an interesting but routine type of muscular contraction that seems like a paradox: the muscle is contracting even as it is lengthening! Eccentric contraction is a bit physiologically mysterious, and is known to be harder on muscle, causing more soreness (quadriceps after hiking down a mountain is the classic example). It may be a good stimulus for adaptation in tendon as well as muscle.   A weird bit of muscle physiology   Jul 21, 19Jul '19 2,750
IT Band Pain is Knee Pain, Not Hip Pain   Pain in the hip and thigh is something else, I promise   Jul 20, 19Jul '19 2,200
Why So “Negative”?+I criticize many poor ideas in health care, so I often seem “negative,” especially to people who truly believe in treatments I debunk. But defending patients from false hope and fraud is a Good Thing, I also report on many effective treatments, and I have fun taking my subject seriously. Not so negative after all!   Answering accusations of negativity, and my reasons and methods for debunking bad treatment options for pain and injury.   Jul 19, 19Jul '19 7,000
Pain & Injury Survival Tips   Dozens of ideas (and links) for evidence-based rehabilitation and self-treatment for common pain problems and injuries   Jul 17, 19Jul '19 14,000
Salamander and Regeneration Science   Why does PainScience.com have a salamander mascot? Their regenerative superpower is an inspiring, profound example of what is possible in biology and healing   Jul 9, 19Jul '19 2,200
Basic Self-Massage Tips for Myofascial Trigger Points+

Massage therapy isn’t cheap, but you can do some of the work for yourself. Self-massage might seem like trying to tickle yourself, but you may be able to relieve a lot of discomfort by treating your own “trigger points”: sore spots in muscle tissue that often seem to yield to rubbing. It is a safe, cheap, and reasonable experimental approach to self-help for many common pain problems, even though there are many reasons it might fail. No advanced technique is required: it’s mainly just a matter of finding sore spots in troubled areas that feel relevant and briefly applying direct mild to moderate pressure.

  Learn how to massage your own trigger points (muscle knots)
  Jul 3, 19Jul '19 2,750
Painful Lessons   What I’ve learned from twenty years of studying pain   Jun 24, 19Jun '19 1,500
Muscle Pain as an Injury Complication   The story of how I finally “miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had healed   Jun 6, 19Jun '19 4,250
Your Back Is Not Out of Alignment+

“Structuralism” is the excessive focus on physical abnormalities in musculoskeletal medicine, things like tilted pelvises, short legs, abnormal spinal curvatures, or misaligned anything. These “biomechanical bogeymen” are the source of much therapeutic barking up the wrong tree. Although some factors like these do sometimes matter, they are collectively much less important than most people believe, and they tend to overshadow many other important biological and neurological considerations.

The paradigm of structuralism has dominated musculoskeletal medicine for decades, but since the early 2000s it has been challenged by many medical researchers and experts, and many key scientific studies over the years have undermined major structuralist assumptions, like Finan’s finding that knee pain correlates more with pain sensitivity than arthritis; Grundy’s conclusion in Lancet that short leg length differences don’t correlate with back pain; or Grob’s findings that abnormal neck curvatures do not predict neck pain; or Moseley’s finding that a placebo for knee osteoarthritis is just as good as real surgery; or numerous MRI studies showing terrible correlation between structural problems and back pain (see Boden, Jensen, Weishaupt, Stadnik, Borenstein); or the astonishing finding by Haig that even narrowing of the spinal canal does not necessarily cause stenotic back pain; or the clear evidence that even dislocation of the upper cervical spine is often asymptomatic (Swinkels); and so on (and on and on).

Structuralism is a simplistic old paradigm that needs to be replaced with more nuanced model of what causes and complicates aches, pains, and injuries.

  Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain
  May 27, 19May '19 21,000
Massage Therapy for Tennis Elbow and Wrist Pain   Perfect Spot No. 5, in the common extensor tendon of the forearm   Apr 27, 19Apr '19 1,800
The 3 Basic Types of Pain+

There are two main classifications of pain: the common sensical sort that arises from damaged tissue (nociceptive pain), and the more exotic kind that comes from damage to the system that reports and interprets damage, the nervous system (neuropathic pain). This is the difference between engine trouble and trouble with that light on your dashboard that claims there’s engine trouble. Oddly, there is still no clear, official “other” category for the pain of conditions like fibromyalgia and irritable bowel syndrome, which see to involve dysfunction of the nervous system, as opposed to damage; historical names like functional pain have many problems, and new names like nocipathic, algopathic, or just primary pain are on the table.

Nociception and pain are not equivalent and there are no “pain fibres,” just nerves that send data to the brain for consideration. All pain is technically a brain-generated experience. However, the illusion that pain is “in” our body is meaningful and functional.

Pain can also be classified as somatic (skin, muscle, bones, joints) and visceral (organs).

  Nociceptive, neuropathic, and “other” (and then some more)
  Mar 17, 19Mar '19 5,500
The Unstretchables+Many muscles are too awkward to stretch effectively for biomechanical reasons — you simply can’t get good leverage, or another body part is in the way. There are many interesting examples.   Eleven muscles you can’t actually stretch hard (but wish you could)   Mar 16, 19Mar '19 5,000
Stuck in My Throat+

Globus pharyngeus is the sensation of a lump in the throat in the absence of any apparent physical obstruction in the throat, often considered psychosomatic. It’s common and may just be a minor sensory anomaly, like tinnitus. For a sensory phantom, globus can be a serious bully, interfering with swallowing and even breathing at worst, and causing severe anxiety about the possibility of scary causes like cancer. Unfortunately, it’s almost impossible to confidently rule out a medical cause in the short term.

Globus is “all in your head” unless it isn’t. Unfortunately, the diagnostic challenge of is immense. Many subtle or obscure problems can be at the root of it, but some globus sufferers eventually get answers and relief from the discovery of causes like tonsil stones, acid reflux, minor injuries to pharyngeal stuctures, Eagle syndrome, cysts and cervical osteophytes, and other oddball anatomical abnormalities, mostly minor — just anything that irritates the throat.

  A “globus pharyngeus” nightmare, with a side of science
  Mar 12, 19Mar '19 8,500
Massage Does Not Reduce Inflammation+A unreplicated and deeply flawed 2012 scientific study (Crane et al.) claimed to find that massage reduced inflammation in intensely exercised muscles. The profession of massage therapy took the conclusions at face value and claims that massage “reduces inflammation” are now common.   The making of a new massage myth from a high-tech study of muscle samples after intense exercise   Mar 10, 19Mar '19 5,500
Trigger Points on Trial   A summary of the kerfuffle over Quintner et al., a key 2014 scientific paper criticizing the conventional wisdom about trigger points and myofascial pain syndrome   Feb 19, 19Feb '19 5,000
Diagnosing Runner’s Knee+There are two types of runners knee, mainly distinguished by location: pain on the SIDE of the knee (IT band) versus pain on the FRONT of the knee (patellofemoral), but there are several other key differences.   It usually starts with lateral knee pain during and after runs, but there are two major types   Jan 5, 19Jan '19 2,300
Contrast Hydrotherapy   “Exercising” tissues with quick changes in temperature, to help with pain and injury rehab (especially repetitive strain injuries)   Dec 12, 18Dec '18 3,500
Massage Therapy for Low Back Pain (So Low That It’s Not In the Back)   Perfect Spot No. 12, a common (almost universal) trigger point in the superolateral origin of the gluteus maximus muscle   Nov 14, 18Nov '18 3,000
What Can a Runner With Knee Pain Do at the Gym?   Some training options and considerations for runners (and others) with overuse injuries of the knee   Nov 10, 18Nov '18 4,000
Does Ultrasound Therapy Work?+

Ultrasound therapy is the use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries (sprains, tendinitis, bursitis). It has been a popular therapy for decades, its use so widespread that it almost defines physical therapy. Unfortunately, although mainstream, it is not as scientific a treatment as most people assume. It has been condemned or, at best, damned with faint praise by one scientific review after another for a quarter century. Authors had almost nothing good to say about ultrasound. Conclusions like this one (from van der Windt et al) are the rule: “As yet, there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders.” Some modern variants of ultrasound are expensive, hyped, and totally unproven for any or many conditions.

  Many concerns about the widespread usage of therapeutic ultrasound, especially extracorporeal shockwave therapy (ESWT)
  Oct 26, 18Oct '18 6,000
The Not-So-Humble Healer   Cocky theories about the cause of pain are waaaay too common in massage, chiropractic, and physical therapy   Oct 26, 18Oct '18 4,250
Tennis Ball Massage for Myofascial Trigger Points   Some creative tips on using a tennis ball (and other tools) to self-massage myofascial trigger points   Oct 19, 18Oct '18 2,400
Deep Cervical Flexor Training   “Core” strengthening for the neck   Oct 12, 18Oct '18 1,000
The Insomnia Guide+

Serious insomnia, chronic and intense, is nothing to mess around with. Pain and insomnia in particular are trapped in a dysfunctional relationship, each causing the other. Fortunately, insomnia is often basically a bad habit that responds well to behavioural conditioning (just be sure to eliminate medical causes of sleep troubles first, especially the common sneakier ones like delayed sleep phase syndrome). There are many simple ways to improve sleep “hygiene” (rituals and behaviours that affect sleep) and the challenge is mainly in being thorough and consistent. Sleep compression therapy is more difficult but critical: temporarily cramming sleep into limited hours to force consistent, habit-building timing of falling asleep and (especially) waking up.

  Serious insomnia-fighting advice from a veteran of the sleep wars
  Oct 9, 18Oct '18 11,000
Pain Relief from Personal Growth   Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness   Sep 29, 18Sep '18 4,250
(Almost) Never Use Ice on Low Back Pain!+

Icing is a popular treatment option for back and neck pain. Neither icing nor heating have much potential to actually relieve acute back pain, but ice is relatively likely to actually backfire. The effects of icing and heating are dominated by the mind, by our expectations and preferences, not their biological effects. Any minor anti-inflammatory effect of icing is usually wasted because there’s less inflammation and injury in back pain than people think, and even when it is a factor it’s usually too deep in the tissue to be affected by ice on the skin. But ice can dial-up pain sensitivity: it’s far more likely to make us “tense up.” Patient preference is key, but there are good reasons to err on the side of heat, and ice should only be used on the backs of patients who clearly prefer it (for whatever reason)… or when there’s clearly a fresh and superficial injury.

  An important exception to conventional wisdom about icing and heating
  Sep 29, 18Sep '18 3,500
Toxins, Schmoxins!+

The idea of “toxins” is usually used as a tactic to scare people into buying some kind of de-toxifying snake oil. Obviously there are dangerous substances; the problem is with the kind of people who toss the idea around, the reasons they do it (fear, profit, ignorance), and because toxin claims are usually so vague that they are literally meaningless, except as a marketing message. Indeed, “detoxification” may be the single most common marketing buzzword in alternative health care.

The body deals with undesirable molecules in many ways. It eliminates some and recycles others; some are trapped in a safe place; and quite a few can’t be safely handled at all (metals). Most alleged “detox” treatments are focused on stimulating an excretion pathway, like sweating in a sauna. But it’s not like sweating is broken and the sauna is fixing it! The only truly “detoxifying” treatments help the body eliminate or disarm molecules the body cannot process on its own. A stomach pump for someone with alcohol poisoning is literally “detoxifying.” So are chelation for heavy metals, and antivenoms.

I cover the specific idea of “flushing” toxins in Why Drink Water After Massage? (Massage is wonderful for all kinds of reasons — it doesn’t need the support of the idea that it detoxifies.) For more general consumer advocacy and education about toxins, see “Detoxification” Schemes and Scams (from QuackWatch.org).

  The idea of “toxins” is used to scare people into buying snake oil
  Sep 25, 18Sep '18 2,200
Knee Surgery Sure is Useless!   Evidence that arthroscopic knee surgery for osteoarthritis is about as useful as a Nerf hammer   Sep 8, 18Sep '18 1,600
Why Drink Water After Massage?+It’s just polite to offer patients a glass of water after a treatment. But therapists who make a production of it as a necessary part of the therapy are just proving their ignorance.   No reason! Massage therapy does not flush toxins into the bloodstream, and water wouldn’t help if it did   Sep 1, 18Sep '18 5,500
Therapy Babble   Hyperbolic, messy, pseudoscientific ideas about manual therapy for pain and injury rehab are all too common   Aug 29, 18Aug '18 5,000
Extraordinary Health Claims   A guide to critical thinking, skepticism, and smart Internet reading about health care   Aug 29, 18Aug '18 4,500
A Historical Perspective On Aches ‘n’ Pains+

We can put a man on the moon, but we can’t fix most chronic pain. The science and treatment of pain was neglected for decades while medicine had bigger fish to fry, and it remains a backwater to this day, despite significant recent progress. The seemingly simpler “mechanical” problems of musculoskeletal health care have proven to be surprisingly weird and messy (but fascinating, at least). Even sports medicine has been strangely slow to build its evidence base, despite elite athletes being worth trillions of dollars to our economy.

Clinically, the field is still dominated by obsolete conventional wisdom and the speculations of desperate patients and opportunistic cure purveyors. For every mainstream medical myth, there are three about aches and pains and injuries, and snake oil thrives. Ignorance is widespread thanks to professional pride and tribalism, ideological momentum, screwed up incentives, and poor critical thinking skills. But the worst single offender is probably the pernicious and nearly unanimous oversimplification of treating the body too much like a complex mechanical device (“structuralism”).

And so people with severe unexplained body pain, or injuries that just won’t heal, bounce around the medical system like they are in a pinball machine, serially misdiagnosed and mistreated, often never finding a professional who recognizes the problem, or — having at least recognized it — has a clue what to do about it.

  We are living in a golden age of pain science and musculoskeletal medicine … sorta
  Aug 9, 18Aug '18 3,000
Studying the Studies   Tips and musings about how to understand (and write about) pain and musculoskeletal health science   Jul 7, 18Jul '18 4,750
Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain   Perfect Spot No. 4, an area of common trigger points in the odd scalene muscle group in the neck   Jun 13, 18Jun '18 3,750
Microbreaking+Microbreaks are regular, small breaks from being stuck in one position at work. It’s a survival strategy for chair-bound office workers, based on the (debatable) idea that sitting too much is Bad For You. It probably isn’t all that bad, but there are still good reasons to microbreak.   Lots of little breaks may help compensate for too much time spent in chairs   May 12, 18May '18 3,250
Does Hip Strengthening Work for IT Band Syndrome?   The popular “weak hips” theory is itself weak   Apr 24, 18Apr '18 3,500
Deep Friction Massage Therapy for Tendinitis   A guide to a simple self-massage technique sometimes helpful in treating common tendinitis injuries like tennis elbow or Achilles tendinitis   Mar 1, 18Mar '18 5,500
You’re Really Tight   The three most common words in massage therapy are pointless   Jan 27, 18Jan '18 2,750
Is Running on Pavement Risky?   Hard-surface running may be a risk factor for running injuries like patellofemoral pain, IT band syndrome, shin splints, and plantar fasciitis   Jan 21, 18Jan '18 8,500
Water Fever and the Fear of Chronic Dehydration   Do we really need eight glasses of water per day?   Jan 14, 18Jan '18 4,250
Mobilize!   Dynamic joint mobility drills are an alternative to stretching, a way to “massage with movement”   Jan 12, 18Jan '18 7,500
Placebo Power Hype+Placebo is fascinating, but its “power” isn’t all it’s cracked up to be: the power of belief is strictly limited and accounts for only some of what we think of as “the” placebo effect. There are no mentally-mediated healing miracles. But there is an awful lot of ideologically motivated hype about placebo!   The placebo effect is fascinating, but its “power” isn’t all it’s cracked up to be   Dec 18, 17Dec '17 7,500
Do Nerve Blocks Work for Neck Pain and Low Back Pain?   Analysis of the science of stopping the pain of facet joint syndrome with nerve blocks, joint injections, and nerve ablation   Dec 9, 17Dec '17 3,000
Healing Time+

Healing speed is of great interest, and people often believe that treatment X helped them to heal faster. It’s also a common marketing claim. Unfortunately, most patients aren’t the least bit knowledgeable about what constitutes a normal healing time, and should probably defer to clinicians who have seen hundreds or even thousands of examples — except that they don’t really know either, because they do know that healing time varies wildly depending on countless variables. People often recover faster or slower than expected for reasons no one can ever know. We also seem to recover faster or slower depending on which psychological “goggles” we have on (optimistic, pessimistic, etc).

The bottom line is that the natural variation in healing times tends to obscure the effects of treatments, and simply isn’t actually possible to know if any treatment helped us heal “faster,” because we can never know how long it would have taken without it. You also don’t know what will happen the next time. The only possible way to settle such questions and confirm a faster average recovery time — especially if it’s only a little bit faster — is with carefully designed scientific testing, and quite a bit of it.

  Can healing be hurried? Would we even notice if it was?
  Dec 4, 17Dec '17 1,700
IT Band Stretching Does Not Work   Stretching the iliotibial band is a popular idea, but it’s very hard to do it right, and it’s probably not worth it   Dec 1, 17Dec '17 3,500
The Art of Bioenergetic Breathing   A potent tool for personal growth and transformation by breathing quickly and deeply   Nov 16, 17Nov '17 3,000
Can Massage Damage Nerves?   It is possible, but hard to do, rare, and the damage is usually minor   Nov 10, 17Nov '17 2,300
Dupuytren’s Contracture   The tip of a mysterious pathological iceberg   Nov 2, 17Nov '17 1,400
Massage Therapy for Low Back Pain (Again)   Perfect Spot No. 13, The Most Classic Low Back Pain Trigger Point   Nov 1, 17Nov '17 1,700
How Many Muscles In the Human Body?   A slightly tongue-in-cheek tally of our many muscles   Oct 13, 17Oct '17 1,500
Why Do We Get Sick?   The curious and tangled connections between pain, poor health, and the lives we lead   Oct 7, 17Oct '17 4,000
Is Diagnosis for Pain Problems Reliable?   Reliability science shows that health professionals can’t agree on many popular theories about why you’re in pain   Sep 23, 17Sep '17 3,250
Tissue Provocation Therapies+

There are two “laws” of tissue adaptation, one each for hard and soft tissue. Wolff’s law is that bone will change and strengthen in response to loading. This was first noticed by Julius Wolff in the 19th Century, who got the naming rights. It was greatly refined in the mid 20th century by Dr. Harold Frost, an American surgeon who studied bone biology, and published scientific papers more often than I change my socks. The full details of how bone responds to stress are described in his Mechanostat model. The corollary in soft tissue is the obscure and much less developed Davis’ law. (No one even seems to know who Davis was.)

Although there’s no question soft tissue does adapt to stress, the responses of muscles, tendons, and ligaments are much more complex and less well understood. Many treatments are based on the idea of forcing adaptation or “toughening up” tissues by stressing the tissues. It has always been a reasonable idea, but the devil is in the details: what constitutes the “right” amount and kind of stress is difficult to know, and the results of such therapies have generally been highly inconsistent.

  Can healing be forced? The laws of tissue adaptation & therapies like Prolotherapy & Graston Technique
  Aug 16, 17Aug '17 4,000
Homeopathy Schmomeopathy+

Homeopathy is a 200-year-old medical philosophy that has been thoroughly debunked, and survives today thanks to wishful thinking, ignorance, and because it is too useless to be very dangerous. It is the flagship in the alternative medicine fleet: the most profitable, absurd, and snakey of all snake oils.

Most people have no idea just how strange homeopathy is. The deal-breaker for many consumers is the discovery that it’s not just an “herbal” or “natural” remedy, but a “magical” one, based on a principle that reeks of flaky physics and old-timey snake oil flamboyance—much farther out in left field than herbs. Some people, of course, are quite happy citing quantum physics to explain alternative medicine, but you really have to be a card-carrying new age sort to go there. For most people, that crosses a line.

But they have to find out first! Fortunately, doctors, scientists and skeptics are unanimously and harshly critical of homeopathy, and have published many good quality critical reviews. For instance, see my own article about homeopathic arnica — the most popular of all homeopathic products, intended to treat inflammatory pain.

  Homeopathy is not a natural or herbal remedy: it’s a magical idea with no possible basis in reality
  Jul 26, 17Jul '17 1,600
Does Arnica Gel Work for Pain?+

Homeopathic (diluted) herbal ointments featuring Arnica are supposedly good medicine for muscle pain, joint pain, sports injuries and bruises, but their effectiveness has been questioned by many experts. Known to most customers as “herbal” cream, most contain less than 10 micrograms of actual arnica per dose—much less that what’s needed for most substances to be considered a chemically active ingredient. Homeopathy is based on a fanciful interpretation of physics that involves ingredients having medicinal effects even after being diluted to the point of literally removing them—no detectable trace of them. Some of the herbal ingredients are less diluted and may be chemically active and more useful.

A few tests of homeopathic pain creams—diluted to varying degrees—have been slightly encouraging, but only the poorer quality ones. In all good quality, modern scientific trials so far, they have performed no better than placebo. It’s still possible that a benefit might be proven, but unlikely.

  A detailed review of popular homeopathic (diluted) herbal creams and gels like Traumeel, used for muscle pain, joint pain, sports injuries, bruising, and post-surgical inflammation
  Jul 26, 17Jul '17 11,000
Massage Therapy for Tension Headaches   Perfect Spot No. 1, in the suboccipital muscles of the neck, under the back of the skull.   Jul 20, 17Jul '17 2,500
The Power of Barking   A silly metaphor for a serious point about correlation, causation, and how we decide what treatments work   May 17, 17May '17 2,300
Massage Therapy for Back Pain, Hip Pain, and Sciatica   Perfect Spot No. 6, an area of common trigger points in the gluteus medius and minimus muscles of the hip   May 15, 17May '17 2,100
Spinal Fracture Bracing   My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace   May 12, 17May '17 2,300
Icing for Injuries, Tendinitis, and Inflammation   Become a cryotherapy master   Apr 22, 17Apr '17 7,000
Ice versus Heat for Pain and Injury+Once and for all, learn when to ice, when to heat, when not to, and why. In a nutshell, ice is for fresh injuries, and heat is for stiff, aching muscles, especially back pain. But the devil is in the details, and there are a lot of them.   When to use ice, when to heat, when not to, and why   Apr 18, 17Apr '17 1,600
Digital Motion X-Ray+

Digital motion X-ray (DMX) is an X-ray video: many X-ray images strung together to make a movie. The output is impressive. In theory, it can reveal serious problems that somehow eluded diagnosis otherwise. In practice, this unregulated and banned-in-Canada technology is primarily sold to neck pain patients by chiropractors, often for evidence in personal injury lawsuits, and is eschewed in medicine because of concern about radiation exposure. DMX undoubtedly has some potential to show important things, but is it worth an increased risk of cancer to diagnose conditions that, mostly, can and should be diagnosed any other way? It’s not completely out of the question, but you should get multiple medical opinions and think hard before resorting to this exotic diagnostic method.

  What’s the risk from the radiation exposure? Is the diagnostic potential worth it?
  Feb 22, 17Feb '17 1,500
Massage Therapy for Low Back Pain   Perfect Spot No. 2, in the erector spinae and quadratus lumborum muscles in the thoracolumbar corner   Jan 27, 17Jan '17 1,800
Wobble Cushions for the Chair Bound   Why and how people who have to be in a chair all day should sit on a stability cushion like the Disc o Sit or SitFit   Jan 24, 17Jan '17 1,400
Patellofemoral Pain & the Vastus Medialis Myth   Can just one quarter of the quadriceps be the key to anterior knee pain?   Jan 14, 17Jan '17 1,900
Objectivity is Overrated+Objectivity and balance are highly over-rated as journalistic virtues. They are mostly a pretentious delusion, and we should never trust anyone who claims to be objective. Instead of expecting that, look for someone with a “view from somewhere” (Rosen) from someone who isn’t afraid to disclose and own where they are coming from. The ideal is not to be unbiased, but to be biased with integrity.   A response to the common accusation of bias and the mythical virtue of objectivity   Nov 26, 16Nov '16 550
The Trigger Point Identity Crisis   The biological evidence that a trigger point is a lesion in muscle tissue   Oct 11, 16Oct '16 3,750
Do IT Band Straps Work for Runner’s Knee?   The science of knee straps for iliotibial band syndrome (runner’s knee)   Oct 6, 16Oct '16 1,600
Ioannidis: Making Medical Science Look Bad Since 2005   A famous and excellent scientific paper … with an alarmingly misleading title   Sep 15, 16Sep '16 3,250
Toxic Muscle Knots   Research suggests myofascial trigger points may be quagmires of irritating molecules   Sep 6, 16Sep '16 1,900
Micro Muscles and the Dance of the Sarcomeres   A mental picture of muscle knot physiology helps to explain four familiar features of muscle pain   Sep 2, 16Sep '16 3,750
Massage Therapy for Upper Back Pain   Perfect Area No. 11, the erector spinae muscle group of the upper back   Aug 30, 16Aug '16 1,400
Patellofemoral Tracking Syndrome   The beating heart of the conventional wisdom about patellofemoral pain is mostly nonsense   Aug 23, 16Aug '16 3,000
Massage Therapy for Shoulder Pain   Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain   Aug 10, 16Aug '16 2,400
Icing, Heating & Tissue Temperature+

Heating pads and ice packs are supposed to work by warming/cooling underlying soft tissues and joints, but can they overcome the body’s powerful mechanisms for maintaining tisue temperature? The science is incomplete, but suggests that we can change tissue temperature by a few degrees Celsius up to a couple centimetres with rapidly diminishing returns. That’s just enough to affect some muscles and smaller joints, but definitely not enough for many of the bigger ones. Also, almost any amount of fat over the target tissue will render superficial heating or cooling pointless.

  How much do ice packs and heating pads change the temperature of muscle and joints?
  Aug 1, 16Aug '16 1,700
Hydrotherapy, Water-Powered Rehab   A guide to using warm and cold water as a treatment for pain and injury   Aug 1, 16Aug '16 1,700
Does the IT Band Move After All?   An ultrasound study says it does, debunking my debunkery   Jul 20, 16Jul '16 2,000
IT Band & Patellofemoral Pain Defy Common Sense   The science shows that you can’t blame runner’s knee on structural quirks that seem like “obvious” problems   Jul 20, 16Jul '16 1,500
The Bath Trick for Trigger Point Release   A clever way of combining self-treatment techniques to self-treat your trigger points (muscle knots)   Jul 7, 16Jul '16 900
A Recipe for Chronic Neck Pain After Whiplash   Researchers discover some surprising risk factors for chronic neck pain in the aftermath of whiplash   Jun 23, 16Jun '16 1,200
What if You Could Wipe the Chronic Pain Slate Clean?   A short, poignant thought experiment for chronic pain sufferers   Jun 15, 16Jun '16 475
Spinal Subluxation+

Spinal joints can get into a few different types of trouble, but “subluxation” and spinal joints being “out” are not defined clearly enough to be useful, and are quite misleading.

“Subluxation” is mainly a chiropractic idea of some kind of spinal joint dysfunction, with many shades of meaning — too many — depending on who is talking about it. However, it is inextricably entangled with the idea of a spinal joint being “out” of place, and it is this sense of the word that needs some debunking. Many chiropractors attribute great importance to subluxation. Most believe, at the least, that subluxations cause neck and back pain, but — significantly — quite a few of them also believe that subluxations cause a wide variety of other health problems and so they “use spinal manipulation to treat visceral disease” (Homola). Subluxation theory has been both popular and controversial for many decades now, and it has never achieved medical respectability. Many experts, including quite a few chiropractors, deny that spinal subluxations exist in any meaningful sense.

It’s problematic that spinal manipulative therapy — the umbrella term for all kinds of spinal joint “adjustment” — is so often based on such a confusing and controversial concept. Subluxation has too much baggage to be a useful term. Let’s use more modern and specific terminology, and get away from the idea of spinal joints being “out.”

  Can your spine be out of alignment? Chiropractic’s big idea has been misleading patients for more than a century
  Jun 15, 16Jun '16 2,000
Painfully Odd Google Searches   Odd, amusing (and occasionally tragic) Google searches that have led people to this website   May 31, 16May '16 1,300
Chiropractor, Naturopath Training Way Less Than Doctors+

Many alternative health care practitioners, especially chiropractors, claim that they are as well trained as physicians. This is false. Doctor’s academic training is routinely longer, and — more importantly — most of their serious learning occurs during extensive on-the-job training, where they are thrust into demanding clinical environments and supervised for years as they deal with a great variety of clinical situations and many extremely sick and hurt patients. That hands-on phase of their training is where all doctors will tell you that they became professionals — and there is nothing like it in any non-medical health care training.

  Medical training is much longer and better than anything naturopaths or chiropractors normally get
  May 31, 16May '16 1,300
T’ai Chi Helps Fibromyalgia, but It’s Not “Alternative” Medicine   Despite a high profile boost from the New England Journal of Medicine, it’s still just gentle, elegant, and pleasant exercise   May 19, 16May '16 1,200
Back Pain & Trigger Points   A quick introduction to the role of trigger points in back pain   May 12, 16May '16 650
Hot Baths for Injury & Pain   Tips for getting the most benefit from a hot soak, the oldest form of therapy   Apr 23, 16Apr '16 4,250
We Are Full of Critters   The human body is a colony of ten trillion co-operating cells   Feb 17, 16Feb '16 1,000
Ten Trillion Cells Walked Into a Bar   A humourous and unusual perspective on how, exactly, a person is even able to stand up, let alone walk into a bar   Feb 17, 16Feb '16 3,000
How to Find a Good Massage Therapist   Lots of tips for finding good quality medical massage therapy in your area (especially trigger point therapy)   Nov 18, 15Nov '15 7,000
Why Does Pain Hurt?+Research has shown that immune cells (neutrophils) unnecessarily “swarm” sterile injury sites, causing damage and pain with no known or likely benefit as a tradeoff. It’s just a clear error: they appear to have mistaken mitochondria for a foreign organism, a legacy of ancient evolutionary history, and a biological glitch with profound implications about why some painful problems are so severe and stubborn.   How an evolutionary wrong turn led to a biological glitch that condemned the animal kingdom — you included — to much louder, longer pain   Oct 22, 15Oct '15 6,500
Patellofemoral Pain Diagnosis with Bone Scan   If you have anterior knee pain, should you bother x-ray, MRI, CT scan, or bone scan?   Oct 2, 15Oct '15 1,200
Do Women Get More Knee Pain?   The relationship between gender and knee pain, especially runner’s knee (IT band syndrome, patellofemoral pain)   Oct 2, 15Oct '15 1,200
Palpatory Pareidolia & Diagnosis by Touch   Tactile illusions, wishful thinking, and the belief in advanced diagnostic palpation skills in massage and other touchy health care   Sep 17, 15Sep '15 3,500
Applied Kinesiology is Bunk+

Applied kinesiology (AK) muscle testing is a pseudoscientific method of diagnosis used by many chiropractors and naturopaths, and denounced as an absurd parlour trick by everyone else. (AK has no relationship to kinesiology, the legitimate study of human movement.) Practitioners believe that changes in muscle strength, reacting to substances placed in the aura and probing questions, reveal the sensitivities and needs of the patient. This is about as scientific as a ouija board. There is almost no real AK research, of course: no real scientist would bother.

Patients are often impressed by AK, because it exploits potent illusions based on the ideomotor and observer-expectancy or subject-expectancy (power of suggestion) effects. It fools practitioners just as readily as it fools patients: most are deluded true believers, not scam artists.

  The skeptical position on applied kinesiology, a bizarre alternative medicine method of diagnosis
  Jul 16, 15Jul '15 950
Insurance Is Not Evidence   Debunking the idea that “it must be good if insurance companies pay for it”   Jul 9, 15Jul '15 900
A common error in alternative medicine   Amateurish speculation about the biological mechanisms of unproven treatments puts the scientific cart before the horse   Jun 30, 15Jun '15 500
Healing Usually Accelerates   The better you get, the faster you get better, a “delicious cycle” — but what if it doesn’t?   Jun 2, 15Jun '15 1,800
The Medical Blind Spot for Aches, Pains & Injuries+

Doctors lack the skills and knowledge to treat most common aches, pains and injury problems, especially stubborn cases, and even the best are poor substitutes for physical therapists. Many doctors are well aware of this, but some are alarmingly oblivious. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”

Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al. In 2002, Freedman et al wrote: “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” In 2005 in Journal of Bone and Joint Surgery, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” In 2006, Stockard et al found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.”

  Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones
  May 15, 15May '15 750
The Pricing of PainScience.com e-Books   A candid explanation of my prices and how I present them to new visitors   Apr 20, 15Apr '15 1,700
Massage Therapy for Your Pectorals   Perfect Spot No. 9, in the pectoralis major muscle of the chest   Apr 3, 15Apr '15 1,100
What’s a “Claim” in Health Care?+

A claim is any unverified assertion. But not all claims are created equal. In health care and health science, “claim” implies a more self-serving assertion. If a claim could be used as a bullet-point in a sales pitch, it’s more claim-y. If it makes you (or your profession) look better, it’s more claim-y. And the more claim-y it is, the more it needs to be backed up.

This special case of the word claim comes from the thorny ethical challenges with selling care to sick, hurt people. All claims need critical appraisal and verification, but it’s just not as ethically critical if it has no claim-stink. Sagan’s idea that “extraordinary claims require extraordinary evidence” is not just about alien abductions and lake monsters. It’s also, in spirit, about more mundane but self-serving and profitable claims — a more common ethical hazard than truly extraordinary claims.

  In health care, claims often involve a more self-serving assertion
  Feb 19, 15Feb '15 500
Review of The Trigger Point Therapy Workbook   A popular book that promises too much and ignores recent science and controversies, which alienates many physicians and sets patients up for disappointment   Jan 3, 15Jan '15 1,900
Masking Symptoms Is Under-Rated+

“Masking symptoms,” especially with medications, is often maligned because it doesn’t “aid healing” or “treat the root cause.” But masking symptoms can be a perfectly good idea, and it should not be eschewed just because it doesn’t have a real healing effect … because there are very few real healing effects! Maybe none. There are few or no known ways to actually improve on the biological process of healing. We can’t tell the body, “Hey, heal better, will ya?”

“Healing” is mainly about removing impediments to natural recovery, such as continued overuse and excessive stress. It’s not dictated by some mythical power to speed healing, but by a strong understanding of the nature of the problem and what pisses it off and slows recovery. The most idiotically simple example is that bad sprains need to be immobilized for a while, just like a fracture — and maybe that seems “obvious,” but it was actually common practice for decades to recommend excessive early mobilization.

Here’s a classic, trickier example: patellofemoral pain is often misdiagnosed and “treated” with strength training that tends to stress the knee even more, and yet it often works to simply avoid sitting with bent knees, because that position is more biomechanically “intense” than most patients realize. Removing that sneaky knee stress isn’t “healing,” per se, but it’s sure important!

Focus on facilitating natural recovery, and don’t knock a little “symptom relief” along the way.

  Masking symptoms,” especially with medications, is often maligned. But sometimes symptoms need masking!
  Sep 6, 14Sep '14 900
Why “Science”-Based Instead of “Evidence”-Based?   The rationale for making medicine more science-based   Aug 26, 14Aug '14 2,750
‘Reductionism’ Is Not an Insult+

Alternative medicine practitioners often derisively accuse their critics of being “reductionist.” This is intended to sound wise and knowing, but sneering at reductionism is a transparently convenient way to dismiss rational objections to crank theories and flaky bullshit. It insultingly insinuates a lack of vision and savvy about complex systems (like the body). It’s just an ideological gripe, not a meaningful thought, about people who allegedly can’t see the forest for the trees. (This is quite ironic, coming as it usually does from barely-trained dabblers and dilettantes, people who clearly have not exactly mastered either forest or trees.)

Certainly reductionism can go wrong, like nearly any mental mode, but it’s not an intellectual failing. It’s just one of many thinking and reasoning tools … not an all-consuming obliviousness to “the whole.”

  Reducing complex systems in nature to their components is not a bad thing
  Aug 25, 14Aug '14 1,200
Confirmation Bias+

Confirmation bias explains a lot about human nature. Most people know it best as “selective hearing” or “selective memory” — hearing and remembering only what you want to hear (see also “pareidolia”). Confirmation bias is a whole lot more: a dazzling array of devious and largely unconscious mental tactics and thinking glitches that lead people to confirm their beliefs and pet theories. We not only tend to ignore, deny and overlook anything that contradicts our point of view, but we also invariably notice, inflate and or even fabricate anything that supports it.

Confirmation bias is one of the main reasons that The Truth is so slippery, and both amateurs and experts alike are prone to significant thinking errors. There are people who consider it part of their job description to eliminate confirmation bias from their thinking — the best scientists and journalists, for instance — but it’s really difficult. Everyone has confirmation bias: it’s just how minds (don’t) work!

  Confirmation bias is the human habit of twisting our perceptions and thoughts to confirm what we want to believe
  Aug 23, 14Aug '14 1,100
Proprioception, the True Sixth Sense   The vital and strange sensation of position, movement, and effort   Dec 24, 13Dec '13 900
Neck Pain, Submerged!   The story of my curious experiment with dunking severe chronic neck pain   Dec 3, 13Dec '13 5,000
Why Massage Therapy?   An attempt to explain the magic of touch therapy, and why I decided to become a Registered Massage Therapist   Aug 26, 13Aug '13 4,500
The Mind Game in Low Back Pain   How back pain is powered by fear and loathing, and greatly helped by rational confidence   Jul 1, 13Jul '13 1,400
Thixotropy is Nifty, but It’s Not Therapy+Thixotropy is the property of some gels or fluids that are normally thick (viscous), but thin when they are stressed. In the human body, the synovial fluid that lubricates most joints is thixotropic, as is the gelatinous “ground substance,” which is part of all connective tissues such as tendons and ligaments. (Fun fact: semen is also thixotropic.) Thixotropy is one of the reasons that we loosen up a little as we move around, just like engine oil warming up. However, thixotropic effect is not a therapeutic effect, and does not explain “releases” in massage or fascial therapy: it is too minor, slow, and temporary, and connective tissue is too tough.   A curious property of connective tissue is often claimed as a therapy   Feb 19, 13Feb '13 1,000
Massage Therapy for Shin Splints   Perfect Spot No. 3, in the tibialis anterior muscle of the shin   Oct 27, 12Oct '12 2,200
Massage Therapy for Tired Feet (and Plantar Fasciitis!)   Perfect Spot No. 10, in the arch muscles of the foot   Oct 25, 12Oct '12 1,300
Massage Therapy for Your Quads   Perfect Spot No. 8, another one for runners, the distal vastus lateralis of the quadriceps group   Oct 2, 12Oct '12 2,100
How I Recovered from IT Band Pain, Eventually   The story of how I got a nasty case of IT band syndrome in both knees & then studied the condition intensively until I could finally beat it   Sep 12, 12Sep '12 2,750
Quackery Red Flags+When choosing treatments, please be wary of the 3 D’s: treatments that may be dangerous, dubious, and distracting (costly or time-consuming). No pain treatment is perfect, but does it at least make sense? Is it safe? Cheap? Reasonably convenient?   Beware the 3 D's of quackery: Dubious, Dangerous and Distracting treatments for aches and pains (or anything else)   May 31, 12May '12 2,200
Is IT Band Tendinitis Really a Tendinitis?   Recent research has clearly shown that the IT band itself is not the anatomy that gets inflamed, which has significant implications for treatment   Jan 23, 12Jan '12 1,200
A Stretching Experiment+What happens when you stretch your hamstrings intensely for several minutes a day in a steam room? The results of a thorough, careful personal experiment. Your mileage may vary!   What happens when you stretch your hamstrings intensely for several minutes a day in a steam room?   Dec 1, 11Dec '11 5,000
Stretching Injury   How I almost ripped my own head off! A cautionary tale about the risks of injury while stretching   Nov 2, 11Nov '11 1,600
Review of the Backnobber II & Knobble II   Plus four other massage tools from the Pressure Positive Company: the Index Knobber, Jacknobber, Orbit Massager and Tiger Tail   Nov 1, 11Nov '11 2,200
Massage Therapy Kinda, Sorta Works for Back Pain   It works, but not very well, and “advanced” techniques are no better than relaxation massage   Aug 10, 11Aug '11 5,000
A Cranky Review of Dr. John Sarno’s Books & Ideas   Sarno’s methods are historically important, based on a kernel of an important truth that has been blown waaaay out of proportion   Apr 21, 11Apr '11 2,400
Chronic Low Back Pain Is Not So Chronic   The prognosis for chronic low back pain is better than most people realize … especially for Australians in Australia!   Oct 10, 09Oct '09 850
The Anatomy of Vitality   What makes life tick? A poetic romp through the substance of vitality   Jun 27, 09Jun '09 3,250
Endurance Training for Pain & Rehab   Why endurance training might be a wise alternative to strength training (especially when healing from an injury)   Nov 30, 06Nov '06 1,800
PF-ROM Exercises   ‘Pain-free range of motion’ or early mobilization exercises can help you heal   Nov 29, 06Nov '06 1,500
Singing, Breathing, and Scalenes   Connections between singing, breathing, neck pain, and a strange group of muscles   Jun 26, 04Jun '04 2,500