Knots are part of the massage lexicon, they are little swollen, hard tender bits of muscle and are thought to occur when there is injury, possibly in response to increased calcium in the area causing localised bunching of muscle fibres with an inflammatory response.   Except sometimes...

It's a rib! - ribs 2-10 start at the spine and wrap around to form your ribcage before joining your sternum at the front.  These ribs start out pointing backwards and to the side and then after approximately an inch there is a sharpish corner, after which they point to the side and even a little forward.  This corner is called a rib angle and at this point the rib has a joint with the transverse process of the vertebra.  If the vertebra is twisted to one side then that costotransverse joint will be prominent on that side, or if the joint isn't functioning properly the rib may sit a little out of line, or indeed there may be inflammation that can be palpated, all of these will feel like a 'knot' between the spine and the shoulder blade and they will be covered with muscle that may be sore, because it is being permanently stretched over a lump.  

When it's an inflamed facet joint!  In the neck, the little joints on the back of the spine can be felt...and when they are inflammed the soft tissues of the joint swell...and make a lump...that feels like a knot
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All in all, whilst knots may appear over joints, the chances are that if there is a lump localised over a joint it is related to that rather than the overlying muscle.  working on the muscle over the joint may release the joint and resolve the issue but...the issue was not a knot!

I hate this question...but completely understand why patients ask me...and do my very best to answer it honestly...or as honestly as I can.  It goes with "is it better this week?" in the category of difficult questions.

As an osteopath I satisfice, that is to say I am not looking for perfection, I am looking to do enough to allow you to get back to normal activity with no, or minimal pain.  I do that by finding dysfunction and working to resolve it...Or do I?  To the osteopath your body isn't made up of discrete structures, joints, muscles etc which can be checked for dysfunction, repaired and ticked off, that would be lovely but that was of looking at things is completely at odds with the core principles of osteopathy.

Firstly, one of the principles states that "the body is capable of self-regulation, self-healing and health maintenance", or alternatively "the body is its own medicine cabinet".  Now don't get me wrong,I don't believe that we understand how to unlock the body's potential to heal all insults and indeed I doubt that is possible but, I do believe that the treatment I give, is not really the cure, it is, merely removing impediments to the body curing itself.  Realistically, sometimes that is as near a cure as makes no odds.  If a structure is being held awkwardly and a technique releases it then to all intents and purposes it is a cure, but more often the process takes time and there are stages by which treatment allows more normal movement and then that normality of movement  improves tissue health and in turn allows treatment to further increase normality of movement.  This change occurs on many levels:

• The cellular level, where cellular health and function may be influenced by easier and better delivery of nutrients and removal of waste
• At the level of the local tissue, as an aggregate of cellular health
• At the level of the joint, muscle or other structure
• At the level of system, or part of system, the muscular skeletal system, the back. 
• At the level of general health
• Often even the patient's psychological and social spheres will be affected by these changes

and that is where the idea that "the body is a unit" - another core principle - comes in.  Change in the function of one joint is often not the goal.  If somebody wants to be able to pick up their grandchildren again, it is almost irrelevant whether L3-4 moves nicely because it is a very small part of that process that involves hips, back, core muscles etc even if we have identified that the twinge they feel that stops them achieving that goal comes from an inflamed facet joint at L3-4.  Actually that process includes very important non-biological inputs too, confidence in their ability along with support and encouragement.   

So, when someone asks whether it is better than last week, the only person who can answer that is them..really.  I can point to improvements in movement and in tissue tone and texture, but only they can tell me whether they are nearer to achieving their goals and indeed, only they can identify those goals in the first place.    How many sessions you need depends on your goals, your starting point, and how you respond to treatment, mentally as well as physically...as well as effective treatment of appropriate tissues.  

As a rule of thumb, I expect to see significant improvement by 3 treatments (often sooner) but everyone is different, long-standing problems often take more treatment, often the patient gets a lot of benefit from the first few treatments but then the additional benefit from each treatment tapers off...but not always...and sometimes there are additional breakthroughs where significant improvement occurs after a period of relative plateau.  The important thing is communication, I need to understand whether you are feeling benefit and I need to be honest about my best assessment of what can be achieved in the short and medium term and that puts you in control, of what you allow to be done to your body and how much time and money you are prepared to spend.