EXCERPT This page is an adapted and somewhat trimmed down excerpt from my ebook about myofascial trigger points (muscle knots), which creatively explores many other aspects of the science of trigger points. I chose this excerpt because it contains some of the best basic biology writing I think I’ve ever done. Sarcomeres make it easy: they are extremely interesting!
Sarcomeres are the molecular engines that power muscle tissue. Think of them as little microsopic muscles-within-muscles. Micro muscles.
They may also tie our muscles into “knots,” and understanding them may be the key to common muscle pain. What’s in a knot? Here’s the oversimplified, conventional, controversial wisdom since about 1995: a trigger point is an unholy clump of contracted sarcomeres living in a swamp of their own garbage molecules, waste metabolites. Unfortunately, this “energy crisis hypothesis” is imperfect, and could well turn out to be wrong.1 Even normal muscle physiology is still full of mysteries. But almost no matter where the march of scientific progress takes us, it will be worth understanding trigger points in this way for many years to come.
And it will always be worth understanding sarcomeres themselves.
I still remember the day I first learned about sarcomeres, and if you’re encountering them for the first time right now, I hope I can make it just as memorable for you. They were the best example I’ve ever heard, before or since, of how life is chemistry. They are a rare explanatory bridge between something as ordinary as wiggling your toes and an exotic, dazzling protein performance. Without sarcomeres, your heart could not beat, your guts could not digest, your jaw could not flap.And there’s something unusual and beautiful about the way sarcomeres are like an extremely miniature version of the muscles they power. There’s really nothing else going on in our bodies microscopically that so perfectly mimics the macroscopic.
You know how kids are so good at asking a chain of “why” or “how” questions? Well, sarcomeres are the final answer to the chain of kid-questions that starts with, “How do we move?” Sarcomeres are how chemistry lifts barbells. Without sarcomeres, your heart could not beat, your guts could not digest, your jaw could not flap. You would never blink, breathe, or burp. Sarcomeres are the ultimate source of all movement. And they are pure organic chemistry.
And when they get messed up, maybe they hurt. Understand sarcomeres and their failure, and you can make sense of muscle knots, if the energy crisis hypothesis is actually correct. Specifically, troubled sarcomeres could explain (at least) four distinctive clinical characteristics of trigger points:
This sarcomere science below is a just a primer for beginners and a refresher course for professionals. I do want you to appreciate just how weird and wonderful sarcomeres are, but what we’re really interested in is how sarcomeres have a starring role in your muscle knots.
Sarcomeres are long and thin. Wrap a few hundred of them together like a bundle of firewood, and then line that bundle up end to end with a few thousand other sarcomere bundles, and you’ve got yourself a single muscle cell or fibre. Every muscle consists of many muscle fibres, and therefore of many millions of sarcomeres.
Sarcomeres are too small for microscopes. They are closer to the size of molecules than cells. Compared to a muscle cell — which is already mind-bogglingly small, you understand, about 10,000 of them across the width of a fingernail — a single sarcomere is like a grain of wheat in a silo.2 If you were the size of a water molecule, you could wander around inside a sarcomere like a mouse in Grand Central Station On the other hand, sarcomeres are pretty large as molecular-scale structures go. Every sarcomere is a tidy little package of well-organized proteins, and proteins are massive molecules generally, and sarcomere proteins are big even for proteins. If you were the size of a water molecule, you could wander around inside a sarcomere like a mouse in Grand Central Station.3
You wouldn’t think that a package of proteins, not even big proteins, could be all that clever, but never underestimate organic molecules: they have a way of being even more freakishly amazing than suspected by the last generation of molecular biologists — who were already pretty impressed — and sarcomeres in particular can make hardened researchers cry. People who study these things face the possibility of never really understanding their subject, of never even seeing a live specimen doing its thing — live sarcomeres cannot be directly observed.4
Nevertheless, the internal structure of a sarcomere is well understood: imagine overlapping chains of proteins, like the tines of two forks meshed together. To contract the sarcomere, the proteins grab onto each other and pull, increasing the overlap of the tines. To relax, the proteins “just” let go.5
So, we do not completely understand how sarcomeres do what they do — we just know what they do, in principle.
Normally, sarcomeres throughout the muscle contract with amazing coordination, and they even coordinate with the contraction of sarcomeres in other muscles — precise synchronization of activity spanning from the molecular scale to the metre scale! That is, things that are happening at the molecular scale in your shoulder can be synchronized with sarcomere activity in your lower legs.6
Sometimes, however, isolated patches of sarcomeres may spasm independently of the rest of the muscle — just as capriciously as whole-muscle spasms and twitches happen. We know the kinds of stresses that probably provoke this change — cold, overstretch, anxiety, trauma, pain, fatigue — but exactly why these things cause some sarcomeres to over-contract remains a mystery. For whatever reason, the proteins grab onto each other, start to pull, and will not let go. The tines of the fork jam tightly together, completely overlapping and even overshooting each other partially, like interlaced fingers.
One evening recently, I bit the inside of my cheek while vigorously chewing a steak. (I was a strict vegetarian for a decade and a half, from age 20 to 35. Which isn’t really relevant, but it’s nice to get to know your tour guide.) I swore, rolled my eyes at myself, and carried on chewing … on the other side, carefully avoiding my bitten cheek, which was already swelling. It’s hard to avoid biting a swollen cheek, though. I hit it a couple more times that evening, and then — what really got me — a hard bite around 4am. I woke up with the inside of my cheek blaring pain at me. A flashlight showed a fat white bulge deep in my mouth, back where the big molars are close together even with your mouth wide open: the hardest spot to avoid biting. And the more I bit it, the more swollen it got, and the harder it was to avoid biting again.
It took five days to break the cycle. I chewed on dozens of ice cubes. I applied crushed up ibuprofen pills. I cut little pieces of plastic to wedge between the wound and my molars. I had a dozen infuriating setbacks where I bit myself again just as I thought it might finally be calming down. I finally won the battle of the cheek by upping the bite-avoidance ante so far that I basically stopped using my mouth for anything for several hours — I just did everything slack-jawed until the nightmare was over.
There’s a reason they are called “vicious” cyles. Positive feedback is a bitch.
Trigger points are probably not only a vicious cycle, but one that is damned hard to interrupt. Tightly contracted patches of sarcomeres generate a lot of tissue fluid pollution, waste products of sarcomeres that are metabolically “revving” … and those “exhaust” molecules are then accumulating, causing pain and other symptoms, and irritating the trigger point even more. This is called a metabolic energy crisis, and it’s why I’ve been informally calling trigger points “sick muscle” syndrome for several years now.
Of course, “the feedback loop suggested in this hypothesis has a few weak links,” wrote David Simons — one of the doctors who invented the hypothesis, and co-author of the “bible” of trigger point therapy.7 Indeed, it does. He was well aware that several links in the chain of causation were simply guesses.
Nevertheless, some recent research has firmed up the theory.8 Starting with a simpler study in 2005, and then a more thorough one in 2008, a group of scientists using “an unprecedented, most ingenious, and technically demanding technique” have confirmed that there really are irritating metabolic wastes floating in the tissue fluids of trigger points: “… not just 1 noxious stimulant but 11 of them,” Simons explains. “Instead of just a few noxious chemicals that stimulate nociceptors [pain sensors], nearly everything that has that effect was present in abundance.”
Basically, the researchers analyzed tissue samples from in and around trigger points and compared them with healthy muscle tissue. The differences were significant. The tissue of myofascial trigger points is rotten with irritating molecules associated with inflammation, with pain, and with immune function.
The vicious cycle explains why trigger points have the potential to last forever. Many times I have worked on people who have had trigger points in the same location for several decades. My own trigger points are impressively long-lived. I’ve had a barely controllable patch of them in my right hip for a decade now.
Positive feedback also helps to explain why trigger points, even when they do go away, strongly tend to come back. Any well-established trigger point has some reason to be there in the first place: it is a predictable response to some chronic stress or vulnerability in the body. Even if a trigger point could be eliminated on Monday, there’s a good chance that it will be back by Friday. Even if it could be completely eliminated on Monday — the sarcomeres’ proteins restored to a healthy separation, and every trace of metabolic waste flushed away — there’s a good chance that the conditions that led to it in the first place will restore it by Friday.
But more importantly: it’s unlikely that the swamp physiology of the trigger point can be completely eliminated in the first place. No matter what we do to it, there will always be some excessive contraction left, the circulation at least a little restricted, and some junk molecules still floating around in that spot — perfect conditions for the trigger point to flare right back up again.
This squares well with the clinical experience of every patient and professional trying to help: it seems to be easy enough to make trigger points a little better, but incredibly difficult to make them go away completely. Trigger point stubbornness explained. Just like cheek bites.
To continue reading about the science of sarcomeres, see the full trigger points tutorial, Trigger Points & Myofascial Pain Syndrome This article is just 3,000 words and includes just two out of five chapters sarcomeres and muscle pain. The entire book is 122,500 and 193 chapters. In the full version, you’ll learn about why pressing on patches of stuck sarcomeres “hurts like hell but feels like heaven,” why it tends to make people say funny things, and why contracting muscles with trigger points like trying to pull away from an intersection in third gear. It’s all in the complete tutorial. Buy it now ($19.95) or read the first few sections for free.
I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.