I’m starting to think that there may be more myths about massage than truths.1
“You’re really tight” must be the most predictable phrase in massage therapy offices the world over … so what a shame that it’s mostly meaningless. It took me just a few weeks of clinical experience as a junior massage therapist to notice that tissue texture correlates really poorly — like, um, really not at all — with pain or any other symptoms. Tightness mostly indicates … itself.
People with hard, ropy, muscle texture that you could bounce an axe off of … may have no apparent problems with pain or stiffness.
People with doughy soft muscle texture … may feel incredibly stiff and sore.
Mix and match at will: there is no clear pattern. Muscle hardness or tightness is simply not a constant companion of muscle discomfort. Whatever commonly makes muscles feel achey or stiff, it produces no consistent sign of it in their texture.
For a couple of years I remained open minded to the possibility that I simply didn’t have the experience and skill to detect subtleties of tissue texture, but eventually I settled into a comfortable conviction that hard, ropy, “tight” muscle texture is just clinically unenlightening. And indeed, as of 2012, there is now some direct evidence that therapists are unable to reliably detect the painful side of low back or neck pain by feel alone2 — an understandable and unimportant failure.
Statements like “you’re really tight” are a bit of a verbal tic, something automatic — even expected — that massage therapists to say to pass the time and make conversation with clients. Tightness doesn’t even actually have a clear meaning.3 In this context, it is trivial and harmless.
But the words “you’re really tight” are also the opening to a sales pitch. The additional phrase and I can fix it is tactfully omitted but almost always implied. It is one of the simplest ways for a therapist to convince herself and the patient not only that she has special knowledge of their tissues — a misrepresentation at best — but that she has power over it.
The unspoken sales pitch is not so trivial or harmless.
In general, massage therapists are prone to fantasies that they can feel things that ordinary mortals cannot, and zero in on tissue problems with uncanny accuracy. I had an instructor in massage therapy college who promised that we would learn to detect “a grain of sand through a telephone book, and a hand on the other side of a wall.”4
Practice and knowledge of anatomy is valuable, of course. I can’t feel a grain of sand through a wall, but after years of practice I can find your infraspinatus muscle in the dark in about four seconds. Through a thick towel, probably. However, therapists routinely fool themselves into thinking they are feeling things under their hands that are not actually there, or things that are might be there somewhere but cannot possibly be detected with any reliability. They do this because of pride, ideology, active imaginations, and wishful thinking.
This is palpatory pareidolia. Pareidolia is a type of illusion or broken perception in which a vague or obscure stimulus — i.e. subtle textures under your skin — is perceived as it was clear and distinct. Pareidolia is what makes white trash Christians spot Jesus in a T-shirt stain, and why the most famously wrong astronomer in history, Percival Lowell, thought he could see canals on Mars.
Pareidolia is the product of a number of well-known cognitive and sensory distortions, and it has many familiar cousins. Over-interpreted perception has always been a problem for empiricism. We actually do perceive what we want and expect to see. The brain is just fantastically good at making up patterns … and palpation provides some rich opportunities for it.
It is responsible for who-knows-how-many declarations of “tightness.” Here are several other candidates for illusory palpations,5 all common in massage therapy (and chiropractic, and osteopathy):
Massage therapists do have exceptional experience with soft tissue. Perhaps some of the most experienced therapists know muscle texture like a blindfolded painter can tell you what type of paint you’ve dipped her brush in. But even if we can detect amazingly slight differences in tissue texture, that doesn’t know that we know what it means … and pretending otherwise is the thin edge of the wedge of arrogance. It’s not practical, clinical knowledge.
In my practice, I refused to say things that made my knowledge or skill seem “special,” and avoiding “tightness” declarations was the most routine opportunity to be humble. I am not kidding around here: I was conscious of this, and deliberately refused to indulge in this. On the rare occasions when it slipped out, I always hurried to qualified it. Example:
“Wow, your trapezius feel really tight!”
Pause. Think. Hmmm. So?
“Of course, I have no idea what that means, or if I can change it, or if it would matter if I could. But, for the record, they feel pretty bullet-proof!”
Finally, along comes a scientific journal to back me up on all this. About time. This brand spanking new experiment from the Journal of Pain says exactly the same thing I’ve been saying all along, just in science-speak:6
This study confirms clinical findings with heterogeniosity in pain sensitivity and hardness across the upper trapezius muscle.
And I particularly liked this:
Two sites [in the trapezius] with low pressure pain thresholds were typical locations for tender points, and these were the least hard sites.
In a dozen people, carefully measured, the most sensitive spots were not just not particularly hard … they were the least hard. Go figure, eh? So, when therapists look for tight or hard spots, then they may very well miss the tissue that is actually the most sensitive. Perhaps your massage therapist should start saying:
Wow, you’re really soft …
Other professionals often comment on my articles, but rarely have I received any feedback so perfectly in harmony with my point as this note from Alice Sanvito, a massage therapist from Saint Louis, Missouri. Here is her message in full, adding some excellent thoughts of her own. I particularly like what she learned from dissections:
“You’re really tight” is a phrase that makes me cringe for a number of reasons. I prefer to ask questions, the most common one being, “How does that feel?” After having my hands on people for an estimated minimum of 15,000 hours over almost 20 years, yeah, I can feel some stuff. And often I can’t. I rely both on feedback and palpation. People often wonder, though, how I know exactly where to go without them telling me and I think it’s a combination of having learned where the common problem areas occur and my hands picking up subtle changes in the texture of the tissue.
Doing dissections helped me to realize that some “ropey” things that I interpreted as pathological were, in fact, just tendons, like in the erector spinae or the semimembranosis. I once had an inexperienced massage therapist try to get rid of a neurovascular bundle in my upper arm because he felt something “stringy.”
Often enough, I’ll feel nodules or an area of increased tissue tension that’s tender and static pressure or other treatment will soften it and/or relieve the discomfort. It often seems more obvious in some muscles than others. But just as often I don’t particularly feel much at all or I feel something that I question and the client feels no discomfort. So, palpation is part of how I assess but not the only thing I rely on. And I never tell a cient, “Wow, you’re really tight!”
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. 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 or Twitter.
Researchers tested two physicians with training in manual medicine to see if they could detect the painful side of the neck or back by touch alone, feeling for tension in the spinal muscles. In almost two hundred patients, they identified the correct side of 65% of lower back pain and 59% of neck pain — only slightly better than chance.
An odd anomaly occurred in the difference between the left and right side: the examiners were more accurate on the right side with back pain, but better on the left side with neck pain.
The results are underwhelming. Although they did a little better than just guessing, the results suggest that it’s difficult even for expert examiners to detect the location of neck and back pain by feel. As well, they were only attempting to detect the side of pain. Imagine how much worse their performance would have been if they had had to identify the location more precisely, or if the pain could have been anywhere or nowhere. So they barely passed the easiest possible test, and probably would have failed a harder one and done no better than guessing.
An obvious weakness of the study is that only two examiners (of uncertain skill) were tested, and so the results are inconclusive. One would still hope for a better detection, though, even from professionals with only average examination skills.BACK TO TEXT
BACK TO TEXT
Fatiguing exercise can affect muscle pain sensitivity and muscle hardness, as seen with work-related neck and shoulder pain. Objective methods to assess muscle pain sensitivity are important because the reliability of manual assessment is generally poor.
The aim of this study was (1) to compare coexistence of tender points identified by manual palpation and pressure algometry or hardness assessments and (2) to examine the influence of exercise on muscle pain sensitivity and hardness. Fourteen sites in the upper trapezius muscle were selected for assessments in 12 healthy subjects.
Pressure pain thresholds and muscle hardness were examined by computer-controlled pressure algometry at baseline, immediately after static or dynamic exercise, and 20 minutes after static or dynamic exercise. Before recording of pressure pain thresholds, the trapezius muscle was examined for tender points by manual palpation.
Two sites with low pressure pain thresholds were typical locations for tender points, and these were the least hard sites. However, manually detected tender points were often (29%) not colocalized with most sensitive sites according to the pressure algometry. A heterogeneous distribution of pressure pain sensitivity and muscle hardness was found in the upper trapezius. The short duration of exercise until exhaustion did not change muscle sensitivity or muscle hardness in asymptomatic muscles.
PERSPECTIVE: This study confirms clinical findings with heterogeniosity in pain sensitivity and hardness across the upper trapezius muscle. Developments of new techniques that objectively identify tender points are important, but thus far, manual palpation is best clinical practice.