I’m starting to think that there may be more myths about massage than truths, like “massage increases circulation” and “massage detoxifies” and several more.1 This is an article about just one of them: the belief that palpable “tightness” matters.
“You’re really tight” is the phrase most likely to be heard 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, ropey muscle texture that you could bounce an axe off of … may have no apparent problems with pain or stiffness.
People with soft, doughy 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 people feel achy or stiff, it produces no reliable objective sign of it in their tissue texture. Similarly, stiffness may have nothing to do with any actual limitation of movement: it’s just a symptom, a subjective sensation of restricted movement with many causes. (See Why Do Muscles Feel Stiff and Tight?)
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. In an interesting scientific test, a couple experts could not reliably detect the painful side of low back or neck pain by feel alone2 — an understandable and unimportant failure.
Why do massage therapists comment on tightness so much?
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. In this context, it is trivial and harmless.
But the words “you’re really tight” are also serve the same purpose as a sales pitch. The additional phrase “and I can fix it” is tactfully omitted but strongly 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 also that she has therapeutic power over it.
The tightness that a massage therapist claims to be able to feel is supposedly an objective sign of the stiffness that patients feel — the symptom that they are selling a solution to.
Stiffness is rarely literal: it’s a vague, subjective sensation, a kind of mild pain, that does not correlate with actual limitations of range of motion.3 Talking about tightness suggests an uncanny ability to feel your pain. The therapist is saying, in effect, “I can tell that you are feeling stiff, because I can feel your tight muscles.” This is a good way to impress anyone with a body. It’s like a psychic who tells you, “You are very stressed. You’re under a lot of pressure right now.” Well, who isn’t? Nearly everyone who makes a massage therapy appointment point is stiff!
That unspoken sales pitch is not so trivial or harmless. It’s not as sinister as fraud, but it does systematically, subtly exaggerate and misrepresent the powers of massage therapists.
Massage therapists are prone to delusions 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):
- trigger points or muscle knots6
- fascial restrictions and “releases”7
- vertebral subluxations8
- many kinds of “asymmetries”9
- cerebrospinal fluid circulation10
- energy disturbances or blocked chi11
Massage therapists do have exceptional experience with feeling tissue. Perhaps some of the most experienced therapists really do know muscle texture like a blindfolded painter can tell you what type of paint you’ve dipped her brush in. But even if amazingly slight differences in tissue texture can be detected, that doesn’t know that anyone knows what it means … and pretending otherwise is the thin edge of the wedge of arrogance. It’s not practical, clinical knowledge.
In my massage therapy practice, I refused to say things that made my knowledge or skill seem “special,” and avoiding “tightness” declarations was one of the easiest ways to stay humble. I am not kidding around here: I was conscious of this, and deliberately refused to indulge in it. 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.”
A bit of humility and humour goes a long way.
There’s not a lot, but a 2010 experiment published in the Journal of Pain concludes … what I’d been saying for many years before that. Here’s the science-speak:12
This study confirms clinical findings with heterogeniosity in pain sensitivity and hardness across the upper trapezius muscle.
Two sites [in the trapezius] with low pressure pain thresholds were typical locations for tender points, and these were the least hard sites.
Now in plainer English: In a dozen people, carefully measured, tissue texture and sensitivity pain were variable and not closely linked. The most sensitive spots were not just not all that hard … they were the least hard spots! 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 …
Response from a colleague
Other professionals often comment on my articles, but rarely have I received any feedback so much 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!”
About Paul Ingraham
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.
What’s new in this article?
2018 — Substantial revision. This article hadn’t been touched in a long time and it struck me as too simplistic and glib. It needs more work, but it’s a lot better today than it was yesterday.
- Cramps, Spasms, Tremors & Twitches — The biology and treatment of unwanted muscle contractions
- Why Do Muscles Feel Stiff and Tight? — Maybe your range of motion is actually limited, or maybe it just feels that way
- Quite a Stretch — Stretching science has shown that this extremely popular form of exercise has almost no measurable benefits
- Thixotropy is Nifty, but It’s Not Therapy — A curious property of connective tissue is often claimed as a therapy
- The Unstretchables — Eleven muscles you can’t actually stretch hard (but wish you could)
- An Open and Closed Case — An explanation for a strange duality of muscle sensation observed in massage therapy
See footnote #1 (just below) for a list of links to articles about other massage myths.
The major myths about massage therapy are:
- Massage increases circulation. Probably not… and definitely not as much as a little exercise.
- “Tightness” matters.
- Massage detoxifies. It’s actually the opposite, if anything.
- Massage patients need to drink extra water to “flush” the toxins liberated by massage.
- Massage treats soreness after exercise. Studies have shown only slight effects.
- Massage reduces inflammation. An extremely popular belief based mainly a single seriously flawed study.
- Fascia matters. The biggest fad in the history of the industry.
- The psoas muscle is a big deal. The most overhyped single muscle.
- Massage stimulates endorphins (natural opioid) and reduces cortisol (stress hormone). They do not.
- “Trigger points” are evidence-based. Actually, the science is seriously half-baked.
- Massage therapists have spooky palpation skills. No, it’s just ordinary expertise… and misleading.
And massage is still awesome! It’s important to understand the myths, but there’s more to massage. Are you an ethical, progressive, science-loving massage therapist? Is all this debunking causing a crisis of faith in your profession? This one’s for you: Reassurance for Massage Therapists: How ethical, progressive, science-respecting massage therapists can thrive in a profession badly polluted with nonsense.
- Maigne JY, Cornelis P, Chatellier G. Lower back pain and neck pain: is it possible to identify the painful side by palpation only? Ann Phys Rehabil Med. 2012 Mar;55(2):103–11. PubMed #22341057 ❐ PainSci #54321 ❐
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 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.
- For more detail, see another article on PainScience.com, Why Do Muscles Feel Stiff and Tight? Maybe your range of motion is actually limited, or maybe it just feels that way.
- In the flaky world of massage, the palpation pretension often blends smoothly with the belief in “energy fields” and extrasensory perception. When that teacher spoke of detecting hands through walls, she was most definitely talking about picking up on auras, not infrared radiation or vibrations!
- In each case, the alleged phenomenon may or may not be a real thing. Cerebrospinal fluid is real, and it does indeed circulate, but no therapist can actually detect it reliably — I’d bet against it as confidently as I bet against dowsing or astrology. Fascial restrictions may well be real, and some may even be quite easy to feel, but many alleged detections are wrong and I’m skeptical that finding them matters. And it’s an open question whether or not the concept of trigger points correlates with altered tissue texture, but even if they do it’s likely that there are multitudes of incorrect diagnoses every day.
- People often suffer from sensitive spots in their soft tissues — something the patient can feel, which is not controversial. The sore spots are definitely a thing. It’s much less clear that anyone else can feel them. Massage therapists believe that the soreness usually is associated with a firm nodule, the “knot.” And supposedly those nodules are caused by little muscular micro-cramps, but that’s just a theory, and massage therapists have trouble agreeing on the locations of these things (questionable “diagnostic reliability”). Trigger point therapy may be validated in time, but for now it is really a mess: badly polluted by overconfident and dogmatic belief in its value, chronic over-selling, and poor clinical reasoning based on flawed and simplistic theories about what trigger points actually are. See Trigger Point Doubts.
- The concept of fascial restrictions or dysfunctions has a specific origin in the early 1990s and has never even remotely be validated. Ever since, the clinical significance of fascia has been egregiously over-hyped, all based on the idea of some unspecified trouble with fascia that simply doesn’t exist. For much more information about this bizarre topic, see Does Fascia Matter? A detailed critical analysis of the clinical relevance of fascia science and fascia properties.
- Spinal joints that are “out” are mainly something chiropractors think they can suss out, but many massage therapists also have subluxation delusions. I was trained in “motion palpation” of the spine to detect them, and there is a popular method favoured by massage therapists that is dedicated to treating them (muscle energy technique). Unfortunately, the concept of spinal subluxations was pre-scientific nonsense when it spawned chiropractic more than a century ago, and it’s been nonsense ever since. For much more info, see Does Spinal Manipulation Work? Spinal manipulation, adjustment, and popping of the spinal joints and the subluxation theory of disease, back pain and neck pain
- “Structuralism” is the excessive focus on causes of pain like crookedness and biomechanical problems. It’s an old and inadequate view of how pain works, but it persists because it offers comforting, marketable simplicity that is the mainstay of entire styles of therapy. For more information, see Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
- Our cerebrospinal spinal fluid circulates modestly but rhythmically: that’s just biology. But it’s extremely subtle. Massage therapists believe than they can feel and manipulate that rhythm, to therapeutic benefit … and that’s just delusions of grandeur. See Does Craniosacral Therapy Work? Craniosacral therapists make big promises, but their methods have failed to pass every fair scientific test of efficacy or plausibility
- Therapeutic touch is hands-off aura massage, actual touch not included. It is the main example of so-called “energy medicine” and a close cousin of Japanese reiki. It is naked quackery. Auras do not exist and cannot be felt, let alone manipulated therapeutically. For more information, see The Myth of Healing Hands: Reiki, therapeutic touch, and other “energy medicine” methods are culturally rich but scientifically bankrupt.
- Andersen H, Ge HY, Arendt-Nielsen L, Danneskiold-Samsøe B, Graven-Nielsen T. Increased trapezius pain sensitivity is not associated with increased tissue hardness. J Pain. 2010 May;11(5):491–9. PubMed #20015697 ❐
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.