Sensible advice for aches, pains & injuries

Save Yourself from Muscle Strain!

Muscle strain (pulled muscle) and muscle pain explained and discussed in great detail, plus every imaginable treatment option

by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about
Photo of a young female runner on a bright orange running track, obviously in pain, holding an hamstring muscle strain.

Muscle strains strike most often in the big muscles of the body. But sometimes the pain is not what it seems …

Muscle strain — literally torn muscle tissue — is often extremely difficult to recover from. In 2012, Gene Lawrence, a 74-year-old weightlifter, ripped his quads (and not while lifting). A doctor told him he’d never do a squat again. But Gene’s passion for his sport kept him going. And yet several months later he was on the verge of beating his personal records — a near total recovery.1

You can recover from nearly anything if you are patient and methodical.

But what method? What is muscle injury, and how does it heal? What works? What doesn’t? And here’s a curve ball: is your muscle even actually physically damaged? Muscle strain and pain are usually woven together, and often pain alone is mistaken for injury.

This extremely detailed guide, regularly updated for more than a decade, thoroughly explores the science of injured and hurting muscle.

About footnotes. There are 62 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942. ← That symbol means a link will open in a new window.
Try one!
This is a book-length two-volume tutorial covering every aspect of muscle strain and pain: the nature of the beast (etiology), diagnosis and related conditions, prognosis and worst case scenarios, every myth and controversy, and reviews dozens of treatment options (including a second volume) — every possible way of reducing pain coming from muscle. Plenty of specific advice is offered, but there are no miracle cures. Scientific rigour and currency is a high priority. This page has been regularly updated for 13 years (last update Nov 23, 2018, jump to update log).
I am a science writer & amateur athlete in Vancouver, Canada. I’ve been writing about muscle strains for more than a decade & recovered from several that I’ve gotten while playing sports, mostly ultimate. ~ Paul Ingraham

Muscle strain and pain myths and misconceptions

Believe it or not (and it does seem a bit ridiculous in 2018) muscle pain is still a subject of scientific mystery and many myths and misconceptions. A torn muscle is arguably among the most medically neglected of all common injuries.23 A major recent review couldn’t find enough evidence for conclusions about any of the most popular treatments4 — for an injury that affects the highest profile athletes in the world, playing sports that involve more resources than small nations. It’s a little surprising we’re not further along at this point in history.

“We can put a man on the moon, but … ”

And so, although most muscle pain is relatively simple to diagnose and self-treat, an incredible number of people seek treatment for muscle strains that have been misdiagnosed as something else … or they have “something else” that’s been misdiagnosed as a muscle strain. Strain, pain, spasm, contracture, scar tissue, tone, tension, and stiffness are all poorly understood and routinely confused. They are not only surprisingly complex topics scientifically, but clinicians are not generally aware of the research that has been done. Certainly family doctors are not competent to assess and treat musculoskeletal problems, including muscle strains.5

The world obviously needs more and better information about muscle pain.

So what is a muscle strain exactly?

A muscle “strain” is any physical trauma to muscle caused by force applied along the length of the muscle (tensile force). That foce can be applied by contraction of the muscle itself (active strain), or imposed on it by a stretch (passive strain), but there’s no practical difference between those scenarios.

A strain is also often called a “pulled muscle” or “muscle tear.”

(Note that there is no such thing as a muscle “sprain” — that’s a contradiction.6)

Although you might have problems that make you vulnerable to a muscle strain, the direct cause of every muscle strain is traumatic ripping of the muscle tissue — arg! — usually at the point where the muscle meets its tendon. Muscle will tear under the force of your own muscular contraction, or excessive stretch.

The more muscle fibres are torn, the worse the strain. In the case of a serious strain, the entire muscle may completely rupture — literally ripped in half! Triple arg! (Total ruptures are serious injuries, much worse than partial ruptures.)

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Muscle strains are particularly common in the thigh & groin in soccer, ultimate, hockey & other fast-moving team sports.

Obviously a muscle can also be bruised, crushed, or lacerated, but those are quite different traumas. This tutorial is only about strains, not all kinds of muscle injuries. There’s not much medical mystery involved if you were gouged by a hockey skate. We also won’t discuss full muscle ruptures in much detail, because they are so extreme that they are easy to diagnose — even doctors can do it! 😃

There will be much (much) more detail below about exactly what a muscle strain is, and its complications, and how to treat it, and so on. But before we get into that, it’s important to determine whether or not you actually have a muscle strain, or some other kind of muscle pain.

Part 2


How do you know that you’ve got a muscle strain?

Here is the part where I tell you that you might be reading the wrong thing.

Many people mistakenly think they have an injured muscle, because there are some common problems that feel like an muscle strain.

True muscle strains and especially muscle ruptures are actually surprisingly rare, compared to other causes of muscle pain. Funny thing about this tutorial: most people who find this document, like most people who think they have strained a muscle, have actually not done any such thing — or (just as common) they strained a muscle once upon a time, but the strain healed long ago and has since become an entirely different problem.

This could be you!

Some of the things that get confused with muscle strains are (and these will all be covered in more detail below):

  • Muscle cramps and spasms (charlie horses) are whole muscle contractions, ranging from uncomfortable to those howling, awful attacks that usually afflict the calves and feet.
  • Nasty muscle knots, technically known as trigger points, are small patches of localized muscle spasm and involve no actual damage to the muscle.
  • Delayed onset muscle soreness, a.k.a. DOMS, is that savage muscle soreness we all get after an unfamiliar workout … but it always (really) fades after about three days, guaranteed.
  • Low back pain is a complex phenomenon which routinely gets attributed to muscle strain, when in fact it is very rarely caused by muscle strain. Just about the only time low back pain is ever caused by muscle strain is when you have a sudden, severe onset of pain while trying to move a piano down some stairs … or something like that. (If you have low back pain, stop reading this article right now and head on over to Save Yourself from Low Back Pain!)

Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night

Back in the late 2000s I was enjoying my athletic peak and just barely managing not to embarrass myself with younger and more talented athletes. One hot summer night I was running low on electrolytes: too much sweating, not enough salt intake. (Actually, that’s a surprising myth.7) I was playing “goaltie” (say it like goal-tea) a variant of ultimate: a hard-running Frisbee sport with the same intensity and speed as soccer, but with more jumping.

Both calves spasmed on a jump, bringing me down hard. That was nasty, but it was just the start: as soon as I hit the ground, both sets of hamstrings went off as well, and all that was more than enough to make for a good cramping story … but then my abdominals joined the fray, and that gave me an anecdote I’ll be sharing for the rest of my life.

The cramping all hurt, a lot, but I was too surprised and busy to focus on the pain. If you’ve ever had a strong spasm, you know that there’s a powerful instinct and need to elongate the muscles. Stretching is your only hope of relief. But I had a puzzle to solve: just try to stretch the backs of your legs and your abdominal muscles at the same time. It’s an anatomical impossibility.

Photograph of me playing ultimate, a sport that has caused many cramps and a few muscle strains over the years.

That’s me in the air at the back. Check out that vertical! It was that kind of jump that triggered a massive wave of spasms …

I jackknifed back and forth so violently that the other players wondered if I was having a seizure, but I was simply on my impossible mission to stretch both sides of my body. If I stretched the legs, the abdominals would bunch up; if I stretched them, the leg muscles tried to kill me. After about three tries each way, I realized it couldn’t be done and that my only hope was compromise: to find the least awful position somewhere between the extremes. It meant that neither muscle group would really be stretched at all — but neither would be allowed to fully contract either. I gasped “cramps! lots of cramps!” so everyone knew I wasn’t actually having a seizure … and then waited it out.

Without the power of stretch, the cramps took a long time to fade. It was a long time to endure extremely powerful contractions.

A spasm is capable of injuring muscle. In this case, I was wrenching back and forth, my own muscles in a tug-of-war with each other. These were perfect conditions for injury. Something had to give, and it did — I had mild strains of all the affected muscles, resulting in not just days of soreness but severe soreness for weeks, and a vulnerability to reinjury that was still a problem a full year later.

The spasm here was the strong involuntary contraction of the muscles. The strain was the injury caused by the forces on the muscles.

True muscle strain checklist

Here’s a checklist of the signs and symptoms of a true pulled muscle. If you can say, “Yeah, that’s me,” to all of these, then congratulations: you probably have an actual, certifiable, card-carrying Muscle Strain®.

  • Did it hit you suddenly during strong stretching or a moment of athletic intensity? Were you lifting something way too danged heavy and/or awkward? In other words, did you have an “oh, shit” moment?
  • Is the injury fairly recent? A few weeks old at the most? If it’s been a long time, it’s probably not a muscle strain any more — certainly not an acute one!
  • Do you have just one muscle (or muscle group) that’s both weak and painful to use?
  • Is there a spot in the muscle that’s especially sensitive?
  • Is the skin flushed and hot? Does it look puffy? Is the area raised? Injured muscle fibers swell up to about five times their normal size!8
  • Does the muscle seem deformed? In addition to overall swelling, more sharply defined bumps or depressions can form. If the muscle fibres tear enough, they muscle will be significantly thinned, causing a depression, and adjacent muscle may bunch up.

If you “woke up with it,” or the pain came on slowly over several days, or if it’s six months old, or if the pain isn’t consistently in one particular place … then we’ll be talking about other possibilities. If your real problem is actually a painful “muscle knot,” for instance, you might want to take your knots for a nice massage — but massage is mostly pointless for a strain.

The “oh shit” moment: the most essential sign of muscle strain

Muscle strain cannot occur without an “oh shit” moment. (It’s fun to explain oh-shit moments to my patients — it always gets a laugh!) In other words, it hits suddenly: you know that something nasty has happened, immediately and with perfect clarity. You feel wounded. In physical therapy, this is what we call a history of “sudden onset.”9

If your pain didn’t start suddenly (or very nearly so), it ain’t a muscle strain. Muscle strains are traumatic by nature, almost always occurring during intense athletic activity. The victim says a bad word, perhaps several of them in the case of a grade II injury. In the case of a grade III, there is generally screaming and falling down and probably turning a bit green.

And yet …

Rupture: not as obvious as you’d think!

Complete hamstring avulsions — that is, complete ruptures of muscles where they attach to bones — are not necessarily obvious. They aren’t all as painful initially as they sound (not a strong “oh shit” sign). And according to O'Laughlin et al, they “can be difficult to diagnose acutely due to swelling and patient guarding, which may mask a visibly palpable defect and lead to delays in diagnosis.”10 Yikes!

In that case study, the only diagnosis was “hamstring pain” for several days, before the avulsion was finally confirmed by MRI, and surgically repaired on day 13. It’s not hard to imagine cases where the diagnosis would have taken much longer — too long.

So how would you know? Many of the other signs discussed here would be relatively obvious, especially substantial weakness. If the muscle is actually detached, obvious there will be a loss of strength. With some muscles, the loss is total or close to it.11 In the case of the hamstrings, there are other “strings” that can take over — which is another reason why a hamstring rupture is surprisingly hard to diagnose. The strength loss would be dramatic, probably about one third (because there are three hamstrings: the semitendinosus, semimembranosus, and biceps femoris), but it’s interesting how non-obvious that is.12 But anyone with a hamstring rupture is going to have a significant performance problem.

Location, location, location

Another way of knowing you’ve got a muscle strain is by the location. Muscle strains are much more common in some muscles than others. Every “groin pull” is a muscle strain of one or more of your hip adductors, for instance.

You can strain virtually any muscle in your body, but the commonly strained muscles are:

  • the hamstrings
  • the rectus femoris (the smallest of the quadriceps group, on top of the thigh)
  • gastrocnemius (the muscle that gives the calf its shape)
  • the lumbar paraspinals (thick columns of muscle on either side of the lumbar spine)
  • the biceps

The pattern here is big muscles, which we tend to use for explosive or intense effort. However, a strain is possible in any muscle.

Even more specifically …

Strains often occur where muscles meet tendons, the myotendinous junction. Tendon is the shiny white “bio rope” that connects muscles to bones (in contrast to the bone-to-bone connections of ligaments). Tendons blend smoothly into muscles, like fingers of two types laced together, but at a cellular level. When a muscle contracts, the greatest strain naturally occurs where it pulls, which is of course where the tendon is. All the force converges on the tendon, but it’s not going to give. (In many cases, even bone will give way before tendon does!) Tendon has an extraordinary tensile strength, much greater than steel cable. Instead, the muscle tissue tends to fail close to where it becomes more tendon-y.

It can be hard to tell where this zone of likelihood is. For instance, in the hamstrings, the tendons are quite long and complex, and blend into the muscle along a considerable span. So you can have a myotendinous strain there that is basically right in the middle, between thigh and knee.

The hurtin’ and the weak

You know you have a muscle strain when the muscle feels weak and contraction is painful.

Strength/pain combinations are very useful diagnostically, and a good physical therapist is always looking for such combinations when assessing your case. A “weak and painful” contraction test indicates muscle strain. “Strong and painful” means something else. “Weak and painless” something else again.

Ligament sprains, for instance, do not cause weakness or pain with muscle contraction — except to the extent that sprained ligaments just don’t like to be moved. If you simply clench your muscles in place, without moving, and nothing hurts (much) … that could be a ligament sprain: strong and painless.

Photograph of an ankle being taped with a compression bandage for a sprain.

Is this a sprain or a strain?

Definitely a sprain. Stabilizing a joint like this is for sprained ligaments, not strained muscles. Sprains always occur at joints, especially the ankles, knees & wrists.

Tendinitis is sometimes mistaken for a muscle strain. But tendinitis will not cause significant weakness. It will just hurt: strong and painful.

Muscles strains make muscle contractions really weak and painful.

Now let’s look at the three alternative diagnoses, three common muscle problems that get mistaken for muscle strains: muscle spasms, DOMS, and muscle knots …

Could you have a muscle spasm instead of a strain?

You sure could! Spasms, cramps and “charlie horses” can both seem like a muscle strain and they can also actually cause one…


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Volume I Contents


Volume II Contents (a separate tutorial but delivered automatically with this one, and, yes, it’s much bigger)

  • 1 Introduction
  • 1.1 Trigger point therapy is not a miracle cure for chronic pain — but it helps
  • 1.2 What exactly are muscle knots?
  • 1.3 Why muscle pain matters so much
  • 1.4 How can you trust this information about muscle pain?
  • 1.5 Why are trigger points so neglected by medicine?
  • 1.6 Does your trigger point therapist have the big red books?
  • 1.7 A brief note about the relationship between fibromyalgia and myofascial pain syndrome
  • 1.8 Trigger points may explain many severe and strange aches and pains
  • 1.9 Two typical tales of trigger point treatment
  • 1.10 The myth of the trigger point whisperer
  • 2 Diagnosis
    How can you tell if trigger points are the cause of your problem?
  • 2.1 Trigger point diagnosis is not reliable … but it also may not matter that much
  • 2.2 Where are the charts and diagrams of trigger point locations in this tutorial?
  • 2.3 Quick checklist: classic trigger point symptoms
  • 2.4 Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome
  • 2.5 Negative checklist: symptoms that are probably not caused by trigger points
  • 2.6 If you have trigger points, will your muscles be “tight”?
  • 2.7 Identifying your trigger points by feel
  • 2.8 “Out of nowhere”: a signature symptom of trigger points
  • 2.9 Chasing pain: hurting in all the wrong places
  • 2.10 Nerve pain is overdiagnosed
  • 2.11 Case study: a story about nerve pain that wasn’t really nerve pain
  • 2.12 Morning symptoms: an uncomfortable daily mystery for many people
  • 2.13 From the frying pan of injury pain to the fire of trigger point pain
  • 2.14 Could it be __________? Several specific problems that trigger points get confused with
  • 2.15 Case study: “Bursitis” strikes again!
  • 2.16 Predictably unpredictable: trigger point symptoms are erratic by nature
  • 2.17 All the noise! Trigger points, joint popping, and crepitus
  • 2.18 What are the worst-case scenarios for myofascial pain syndrome?
  • 2.19 Worst Case Scenario 1: Being triggery
  • 2.20 Worst Case Scenario 2: Rare but extremely severe cases of myofascial pain syndrome
  • 2.21 Worst Case Scenario 3: Quick-start trigger points
  • 3 The science of trigger points
    It’s a little half-baked, but at least it’s not boring
  • 3.1 The dominant theory of trigger points spelled out in a little more technical detail
  • 3.2 Micro muscles and the dance of the sarcomeres
  • 3.3 One: The vicious cycle (why trigger points are stubborn)
  • 3.4 Two: Good pain (why pressing on trigger points hurts like hell but feels like heaven)
  • 3.5 Three: Tightness (why stretching is appealing but underwhelming)
  • 3.6 Four: Weakness (why muscles with trigger points are weak and should not be challenged with strength training)
  • 3.7 Everything we just discussed … in a few bullet points
  • 3.8 Triggers for trigger points: what makes patches of sarcomeres go haywire?
  • 3.9 The all-powerful acne analogy
  • 3.10 The evolution of muscle pain: does muscle “burn out”?
  • 3.11 Referred Pain Science (basic)
  • 3.12 Referred pain science (advanced)
  • 3.13 Other trigger point theories
  • 3.14 Quintner: “It’s the nerves, stupid”
  • 3.15 “The bamboo cage” — what immobilization torture can tell us about the nature of muscle pain and massage
  • 3.16 Case study: an example of getting unstuck and feeling “giddy with joy”
  • 3.17 Muscle knots are not inflammatory: the myth of the inflamed myofascial trigger point
  • 3.18 Adhesions and contracture: when trigger points freeze in place
  • 3.19 The science of adhesions: atoms stick to each other
  • 3.20 The scar tissue issue — are you scarred for life?
  • 4 Basic Trigger Point Self-Treatment
    What can you do about garden variety trigger points?
  • 4.1 Downloadable quick reference guide
  • 4.2 Basic self-massage instructions
  • 4.3 How do you know it’s working? Getting a trigger point to “release”
  • 4.4 Basic tips and tricks for better, longer-lasting trigger point release
  • 4.5 Top 5 mistakes beginners make
  • 4.6 What about massage tools?
  • 4.7 Can you damage your nerves when self-massaging?
  • 4.8 Don’t hesitate to recruit amateur help
  • 4.9 A little more perspective on amateur assistance
  • 4.10 How to get adequate professional help
  • 4.11 Common medications that might make a difference (and might not)
  • 5 Advanced Trigger Point Troubleshooting
    What can you do about severe and persistent trigger points?
  • 5.1 A brief detour: why not The Trigger Point Therapy Workbook?
  • 5.2 Fundamental limitations of trigger point therapy, and how to take advantage of them
  • 5.3 Several more treatment mistakes and problems (that you can fix)
  • 5.4 More serious barriers to success
  • 5.5 New evidence that squishing trigger points works at least a little
  • 5.6 Upgrade your self-massage technique
  • 5.7 Don’t get hung up on anatomy, and be persistent
  • 5.8 Focusing on one trouble spot versus “a little bit of everything” — which is the better strategy?
  • 5.9 More information about exactly how to rub (moving strokes)
  • 5.10 Yet more information about exactly how to rub (pressing and holding)
  • 5.11 Using “press and hold” to identify a trigger point release in progress
  • 5.12 Identifying your trigger points by feel (once again, as it pertains to treatment)
  • 5.13 Referred pain is not a diagnostic feature of trigger points!
  • 5.14 Don’t be fooled by “reverse referral”
  • 5.15 Beyond the tennis ball: commercial massage tools
  • 5.16 Commercial massage tools to avoid
  • 5.17 Massage tools: 7 free (or very cheap) and tools from objects not originally intended for massage
  • 5.18 The sock trick
  • 5.19 The bath trick
  • 5.20 Introduction to non-massage self-treatments for trigger points
  • 5.21 Stretching (executive summary)
  • 5.22 Mobilizations: massaging with movement and the Goldilocks zone
  • 5.23 Case study: mobilizations prove to be crucial factor in recovery from neck pain that started in the 1970s
  • 5.24 Trying to squirm your way out of trigger point pain? Don’t do it! Consider a little more method in your madness
  • 5.25 How to take your trigger points to the gym (if you must)
  • 5.26 Thermotherapy
  • 5.27 Breathing deeply is free, safe, and possibly amazing therapy for trigger points
  • 5.28 Neutral positioning: find a comfortable muscle length and rest there
  • 5.29 An introduction to medicating muscle pain (hint: not a great option)
  • 5.30 Anti-inflammatories and Tylenol
  • 5.31 Voltaren® Gel, an intriguing new option
  • 5.32 The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids
  • 5.33 The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines
  • 5.34 Lidocaine patches
  • 5.35 Combination treatments: why and how to throw everything at it but the kitchen sink
  • 5.36 Troubleshooting referred pain: the referred pain field guide
  • 5.37 Case study: referred pain causes a “heart attack” and completely fools dozens of professionals
  • 5.38 Troubleshooting negative reactions to treatment
  • 6 Perpetuating Factors
    What makes trigger points stubborn?
  • 6.1 Troubleshooting “stuck” trigger points — adhesions and contracture
  • 6.2 Troubleshooting stress (without meditation or yoga, unless you like that sort of thing)
  • 6.3 Troubleshooting posture, ergonomics, and muscle imbalance
  • 6.4 Troubleshooting mysterious perpetuating factors
  • 6.5 The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia
  • 6.6 Way beyond stubborn: troubleshooting extreme cases
  • 6.7 Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope)
  • 6.8 What if trigger points only partly explain your chronic pain? Several other causes of chronic, undiagnosed pain
  • 7 Medical Factors That Perpetuate Pain
    The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases
  • 7.1 Some usual, unusual, and unique medical disclaimers
  • 7.2 Getting tested and treated: the hard way, the easy way, and the right way
  • 7.3 Pain-causing drug side effects: statins (cholesterol-reducing drugs) and bisphosphonates (for osteoporosis)
  • 7.4 Nutritional and hormone deficiencies
  • 7.5 Vitamin D deficiency
  • 7.6 Thyroid hormone deficiency
  • 7.7 Iron deficiency (and excess)
  • 7.8 Vitamin C deficiency
  • 7.9 Vitamin B12 deficiency
  • 7.10 Vitamin B1, B2, folate, and magnesium deficiencies
  • 7.11 Testosterone deficiency
  • 7.12 Estrogen deficiency
  • 7.13 Infections
  • 7.14 Inflammation
  • 7.15 Smoking
  • 7.16 Overall treatment strategy
  • 8 Stretching
    Stretching is generally over-rated … but it might be good for trigger points
  • 8.1 The anecdotal evidence for stretching (is just huge)
  • 8.2 Case study: A cautionary tale of stretching: that time I almost ripped my own head off
  • 8.3 Winning a tug-of-war: how stretching might help trigger points in principle
  • 8.4 The bad news about stretching for trigger points
  • 8.5 Like a knot in a bungie cord
  • 8.6 The spray-and-stretch method, if it works, implies that stretch alone may not work
  • 8.7 Other practical limitations of stretching for trigger points
  • 8.8 What about neurology? Stretch tolerance
  • 8.9 What about stretching the antagonist muscle?
  • 8.10 Stretching “conclusions”
  • 9 Getting Help
    How do you find good therapy for your trigger points?
  • 9.1 Types of therapists and doctors and their relationship to trigger point therapy
  • 9.2 Massage quality control issues (“But I’ve already tried massage therapy … ”)
  • 9.3 Two case studies: highly-trained therapists failing miserably
  • 9.4 Worst practices in massage therapy
  • 9.5 How to find good trigger point therapy
  • 9.6 The Pressure Question: how much is too much?
  • 9.7 Pain in three flavours: the good, the bad, and the ugly
  • 9.8 Training your therapist
  • 9.9 Other kinds of therapies
  • 9.10 How about spray and stretch therapy?
  • 9.11 How about the Paul St. John Method of Neuromuscular Therapy?
  • 9.12 How about transcutaneous electrical nerve stimulation therapy? (TENS or ENS)
  • 9.13 How about ultrasound therapy? (ESWT and “Sonic Relief™”)
  • 9.14 How about chiropractic joint adjustment and popping?
  • 9.15 How about myofascial release and fascial stretching?
  • 9.16 How about trigger point injection therapy?
  • 9.17 How about Botox injection therapy?
  • 9.18 How about nerve blocks?
  • 9.19 Maybe stabbing will help! How about Dry Needling, AKA Intramuscular Stimulation (IMS) therapy?
  • 9.20 How about acupuncture?
  • 9.21 Acupressure: what if we pressed those points instead of puncturing?
  • 9.22 How about Active Release Techniques® (ART)?
  • 9.23 Measuring progress in trigger point therapy
  • 10 Final Thoughts
    How is a lemon like a trigger point?
  • 11 Appendices
  • 11.1 Appendix A: Trigger Point Reference Materials or: Diagrams, Diagrams, Diagrams!
  • 11.2 Appendix B: The Perfect Spots
  • Spot #1 for pain almost anywhere in the head, face and neck, but especially the side of the head, behind the ear, the temples and forehead
  • Spot #2 for pain anywhere in the low back, tailbone, lower buttock, abdomen, groin, side of the hip
  • Spot #3 for pain in the shin, top of the foot, and the big toe
  • Spot #4 for pain in the upper back (especially inner edge of the shoulder blade), neck, side of the face, upper chest, shoulder, arm, hand
  • Spot #5 for pain in the elbow, arm, wrist, and hand
  • Spot #6 for pain in the low back, hip, buttocks (especially immediately under the buttocks), side of the thigh, hamstrings
  • Spot #7 for pain in the side of the face, jaw, teeth (rarely)
  • Spot #8 for pain in the lower half of the thigh, knee
  • Spot #9 for pain anywhere in the chest, upper arm
  • Spot #10 for pain in the bottom of the foot
  • Spot #11 for pain anywhere in the upper back, mainly between the shoulder blades
  • Spot #12 for pain in the lower back, buttocks, hip, hamstrings
  • Spot #13 for pain in the low back, buttocks, hamstrings
  • Spot #14 for pain any part of the shoulder, and upper arm
  • 11.3 Appendix C: Trigger Point Therapy Resources
  • 11.4 Acknowledgements
  • 11.5 Reader Comments
  • 11.6 What’s new in this tutorial?
  • 11.7 Notes
Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
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The main buy button is for credit card purchases, but some customers prefer to use PayPal so they don’t have to give a credit card number to a small vendor. My business never actually handles card info (it goes straight from your web browser to, a major payment processor with a great reputation), but …

You can pay with PayPal. Although automatic order processing is only available for credit card customers, you can “manually” login to PayPal and send payment of 19.95 USD to . Please specify the book you are ordering!

I process orders promptly during working hours, usually within two hours, often much less; night orders are processed early the next day. You will receive order confirmation and access information by email.

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  1. Many confirmation emails are mis-identified as junk email. If you don’t one, please check your spam folder!
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How can you trust this information?

I apply a MythBusters approach to health care (without explosives): I have fun questioning everything. I don’t claim to have The Answer for muscle strain and pain. When I don’t know, I admit it. I read scientific journals, I explain the science behind key points (there are more than 60 footnotes here, drawn from a huge bibliography), and I always link to my sources.

For instance, there’s good evidence that educational tutorials are actually effective medicine for pain.?Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902. Researchers tested a series of web-based pain management tutorials on a group of adults with chronic pain. They all experienced reductions in disability, anxiety, and average pain levels at the end of the eight week experiment as well as three months down the line. “While face-to-face pain management programs are important, many adults with chronic pain can benefit from programs delivered via the internet, and many of them do not need a lot of contact with a clinician in order to benefit.” Good information is good medicine!

So all the science and all the options for muscle strain treatment are here. If you’ve been struggling with pulled muscle injury, I think this tutorial will feel like a “good find” to you!

As with all the tutorials on, I’ve worked hard to provide you with the best information available anywhere — not just better researched and referenced, but also regularly updated, and presented in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it, where all your questions get answered.

Part 2.7


Reader feedback … good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

The internet is a dicey place to spend money ... so many scams. I wanted to let you know how appreciative I am of your eBook on muscle strains. When I got to the stop sign, I had to reflect and realized that the style and quality of what you had written was worth a gamble. Well, paying the twenty bucks and learning what I wanted to learn — and more — was worth every penny. I am now rehabbing my level 1 calf strain with full confidence and feel very well informed moving ahead. Good luck and keep writing — we need all the help we can get out here!

~Craig Adkins, tennis player and professional skiing cameraman, Portland, Oregon

I read your article on muscle strains, and I was very impressed. You seem to really know your stuff. I wish there was one of you in every state!


I found this article when I was researching how to heal my pulled muscle. I love the mobilization exercises at the end — great for a ‘desk jockey’ like me!

~Juanita Vannay

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:

  • Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.
  • Too negative specifically. Some are offended by about a treatment option that they personally use and like. Or sell.
  • Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.
  • Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.


Thanks first and most of all to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is a much bigger project. was originally created in my so-called “spare time” with a lot of assistance from family and friends. Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, and actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, Dr. Ravensara Travillian, Dr. Neil O’Connell, Tony Ingram, Dr. Jim Eubanks … oh dear, there’s so many more still …

I work “alone,” but not really thanks to all these people.

Further Reading

Here are several additional articles of interest:

And here are the articles recommended for those of you who may have muscle knots, as opposed to a muscle strain:

What’s new in this tutorial?

Regular updates are a key feature of tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 29 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

NovemberNew section: No notes. Just a new section. [Section: Electric exercise: electrical muscle stimulation (EMS).]

SeptemberNew section: No notes. Just a new section. [Section: Frickin’ laser beams.]

AprilScience update: Added a highly relevant citation to Grassi et al. [Section: Regenerative medicine? Platelet-rich plasma.]

FebruaryCleanup: No new science, but a bunch of clarifications and editorial improvements. It’s a clearer and more useful section. [Section: Prevention: important even after you’ve been hurt.]

FebruaryNew tips: Added two evidence-based tips to help estimate how long a strain takes to heal. [Section: Timing tips: when is it safe to use a torn muscle again?]

2017Expanded: Added some substance, mainly citing and discussing Ramos et al on the lack of evidence for common treatments. It’s still a short introduction to the second half to the book , but not as absurdly brief as it was. [Section: Treatment: What can you do for a muscle strain?]

2017Improvements: Added more information about swelling and muscle deformation. [Section: True muscle strain checklist.]

2017Science update: Added a very interesting good-news reference that actually provides some decent support for massaging strains. [Section: Self-massage of muscle strains.]

2016Expanded: New evidence-based prevention risks and tips. [Section: Prevention: important even after you’ve been hurt.]

2015Minor science update: Citation of Collins 2008 and Bleakley 2012, reviewing icing evidence (or the lack of it), and a few related edits. [Section: Please, do not apply heat to a freshly pulled muscle — use ice!]

2015Expanded: Added discussion of surprising data about rates of reinjury. [Section: Prevention: important even after you’ve been hurt.]

2015Expanded: More than doubled the size of the section with an interesting addition: “Rupture: not as obvious as you’d think!” [Section: The “oh shit” moment: the most essential sign of muscle strain.]

2014Like new: New, but shorter: just a topic summary now, linking to a main, free article. [Section: Regenerative medicine? Platelet-rich plasma.]

2014Science update: More perspective and detailed information on stretching for recovery. [Section: What about stretching? Can it treat or prevent strains?]

2013Science update: A (slightly) good news science update about the effect of stretching on recovery. [Section: What about stretching? Can it treat or prevent strains?]

2013Minor update: Added a couple paragraphs about exactly where in a muscle strains tend to occur, and why. [Section: Location, location, location.]

2013Major update: Much more detailed and evidence-based tips for estimating recovery time. [Section: Timing tips: when is it safe to use a torn muscle again?]

2013Minor update: Upgraded risk and safety information about Voltaren Gel. [Section: You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.]

2012New section: No notes. Just a new section. [Section: Prevention: will water and electrolytes make a difference?]

2011Update: Rewritten and expanded with important evidence about how stretching does not prevent strain injuries. [Section: What about stretching? Can it treat or prevent strains?]

2011Minor update: Added a (very) funny clip from the TV show Glee. [Section: True muscle strain checklist.]

2011Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

2011New artwork: Added a nice new diagram of strain severity. [Section: What’s the worst case scenario for your muscle strain?]

2011New section: No notes. Just a new section. [Section: Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night.]

2011New section: Some useful new information about how to estimate healing time more accurately. [Section: Timing tips: when is it safe to use a torn muscle again?]

2010New section: Another new section and yet more good new evidence about prevention. [Section: Prevention: Warmups work.]

2010New section: New section based on solid new evidence about prevention. [Section: Prevention: can you prevent muscle strains by upgrading your muscle balance?]

2010New cover: At last! E-book finally has a “cover.”

2010New section: No notes. Just a new section. [Section: Regenerative medicine? Platelet-rich plasma.]

Older updatesListed in a separate document, for anyone who cares to take a look.


  1. Bret “The Glute Guy” Contreras tells his story, and some other tales of extreme recovery, and extracts some lessons from them. See You’ll Never Squat Again. BACK TO TEXT
  2. Simons D. Foreword of The Trigger Point Therapy Workbook. 1st ed. New Harbinger Publications; 2001. “Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain.” BACK TO TEXT
  3. You can get a rough measure of how well-studied a subject is by doing a search for it on PubMed, a large database of citations to medical research. Searching for muscle strain is a bit tricky, because “muscle strain” is mentioned in lots of papers that aren’t really about muscle strain. But if you cleverly search for the terms “muscle strain” only in titles, you will get, as of 4/14/07, only 61 search results, even less than iliotibial band syndrome (another under-studied condition). Compare that to, say, 3000 for adhesive capsulitis (frozen shoulder), or 5900 for carpal tunnel syndrome. BACK TO TEXT
  4. Ramos GA, Arliani GG, Astur DC, et al. Rehabilitation of hamstring muscle injuries: a literature review. Rev Bras Ortop. 2017;52(1):11–16. PubMed #28194375. PainSci #52750. BACK TO TEXT
  5. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.
    Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

    Cartoon by Loren Fishman,

  6. Strain and sprain are confusingly similar words for quite different things. They both refer to tearing, but of different tissues. A torn ligament is always called a sprain. A torn muscle is always called a strain. BACK TO TEXT
  7. Was it really the electrolytes? No. That’s what I thought at the time, but a nice myth-busting 2011 experiment comparing crampy runners with their uncramped comrades showed clearly that dehydration was not the culprit. Fun science. See Schwellnus et al. BACK TO TEXT
  8. Rozen, I and Dudkiewicz, I. “Wound Ballistics and Tissue Damage.” Chapter in: A. Lerner and M. Soudry (eds.), Armed Conflict Injuries to the Extremities, 21 DOI: 10.1007/978-3-642-16155-1_2, Springer-Verlag Berlin Heidelberg 2011. BACK TO TEXT
  9. Mild strains can come on relatively slowly. I have experienced at least two “slow” muscle tears of my left quadriceps while playing ultimate (a hard-running Frisbee sport). I recall in each case that there was definitely a moment of injury — but it was kind of a long, drawn-out moment. I stumbled a little. There was some pain, but not enough to stop me at first. As I kept running, though, it became clear that I was going to be benched. I had torn a few fibres, perhaps, and I was tearing more as I ran — a slow rip, a few more fibres with every step. The sense of impending doom was very strong! So, in this case, the onset was not exactly a “sudden” attack of serious pain, but it was still a perfectly clear, well-defined, can’t-miss-it kind of event. BACK TO TEXT
  10. O'Laughlin SJ, Flynn TW, Westrick RB, Ross MD. Diagnosis and expedited surgical intervention of a complete hamstring avulsion in a military combatives athlete: a case report. Int J Sports Phys Ther. 2014 May;9(3):371–6. PubMed #24944856. PainSci #53845. BACK TO TEXT
  11. Example: if you rupture your Achilles tendon, you lose nearly all of your ankle plantarflexion strength. The only muscles pulling on the back of the heel are the gastrocnemius and soleus, which make up almost all the bulk of the calf, and all that strength is funeled into the Achilles tendon. BACK TO TEXT
  12. Imagine you’re a tough athlete, like the guy in the cited case study, a mixed martial arts fighter! How do you feel if you lose about one third of the strength in your hamstrings? You know something’s wrong, for sure … but you’re tough, so you probably don’t make all that much of it. “Doc, I hurt something and I don’t think I’d want to fight right now, but I can still walk around fine.” You don’t need anywhere close to full strength most of the time … so being 30-40% short is really not that big a deal. BACK TO TEXT

There are 50 more footnotes in the full version of this book. I like footnotes & I try to have fun with them whenever possible.

Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
PayPal logo

The main buy button is for credit card purchases, but some customers prefer to use PayPal so they don’t have to give a credit card number to a small vendor. My business never actually handles card info (it goes straight from your web browser to, a major payment processor with a great reputation), but …

You can pay with PayPal. Although automatic order processing is only available for credit card customers, you can “manually” login to PayPal and send payment of 19.95 USD to . Please specify the book you are ordering!

I process orders promptly during working hours, usually within two hours, often much less; night orders are processed early the next day. You will receive order confirmation and access information by email.

Important reminders!

  1. Many confirmation emails are mis-identified as junk email. If you don’t one, please check your spam folder!
  2. Again, please say which book (just the topic is fine, e.g. “plantar fasciitis”).
read on any device, no passwords
refund at any time, in a week or a year
call 778-968-0930 for purchase help