Massage Therapy for Low Back Pain
Perfect Spot No. 2, in the erector spinae and quadratus lumborum muscles in the thoracolumbar corner
Trigger points (TrPs), or muscle “knots,” are a common cause of stubborn & strange aches & pains, and yet they are under-diagnosed. The 14 Perfect Spots (jump to list below) are trigger points that are common & yet fairly easy to self-treat with massage — the most satisfying & useful places to apply pressure to muscle. For tough cases, see the advanced trigger point therapy guide.
People usually don’t know about this spot … until it gets massaged, and then it’s like scratching an itch they didn’t even know they had. Even when they have low back pain caused or complicated by soreness in this patch of muscle, most people think it seems “too high” to be involved. But trigger points here are common,1 and often refer pain downwards, fooling us into thinking our low back pain is lower than it is.
This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest rib and your spine — right where the stability of the rib cage and thoracic vertebrae gives way to the relative instability of the lumbar spine. It consists of trigger points in the upper-central corner of the quadratus (square) lumborum muscle and in the thick column of muscle that braces the spine, the erector spinae.
Technically, these are quite different muscles, but trigger points in either of them usually feel like the same spot — Perfect Spot No. 2.
The anatomy and function of quadratus lumborum and erector spinae
The quadratus lumborum — “QL” for short — is an interesting flat sheet of a muscle, spanning the space between the ribs and the hips. Conventionally, the QL is thought to be a spine-mover, but its probably not much of a spinal muscle, and “its actual role in spinal biomechanics has still to be determined.”2
QL is more likely to mainly be a respiratory muscle; it controls breathing mechanics by pulling down on the 12th rib bottom of the rib cage. Some people with back pain also experience discomfort when breathing. One possible cause of this is a crampy QL, which is pulling down on the lower rib like an action hero clinging to the landing skid of a helicopter.3
The QL may also echo the function of the tough but “forgotten” lumbocostal ligament, which fills the corner between the spine and the 12th rib like a cobweb.4 This ligament tightens when the ribs go up and relaxes when they go down. It limits rib elevation passively, while the QL does it actively. Very respiratory!
But the QL has other jobs: it is active during many actions and activities, some of them counter-intuitive and quite interesting,5 and is an active stabilizer of the spine, a “core strength” muscle, most active in a side plank.6
The erector spina muscle group is an impressive collection of several of layers of muscles, like a thick braid of rope running along the side of the spine. It is primarily responsible for postural stabilization and extension and sidebending of the spine, but these muscle also have some involvement in breathing.7
Every segment of this muscle group from skull to sacrum has the potential to be someone’s Perfect Spot … but there are often significant trigger points at the joint of T12 and L1, right in that thoracolumbar corner, and especially in people with back pain.
How does Perfect Spot No. 2 feel?
Sensation in this area can feel hot and burning if the trigger points are severe, and they can also feel breathtaking — which can be a more “threatening” sensation — so please use caution. However, in the majority of people, a blunted or more gentle pressure will still produce the signature sensation of a Perfect Spot: a deep, sickly “sweet” ache.
How do you find and treat Perfect Spot No. 2?
You can’t easily treat this spot on yourself unless you are unusually flexible or have the right kind of tool … but it’s easy to find on someone else. Simply locate the bottom rib, and then work your way inwards towards the spine. When you hit a thick bundle of muscle beside the spine, you’ve arrived: there is a bit of a natural corner there between a “roof” of rib and a “wall” of spinal muscle.
This area is usually so densely populated with significant trigger points that pressure nearly anywhere is going to feel worthwhile. But keep exploring for the perfect spot. Using thumbs or fingertips if it’s not too sharp, or an elbow or the heel of the hand for a blunter pressure, slowly push into that pocket, and press inwards and upwards. Keep trying different angles and you are likely to find something more attention-grabbing.
A tennis ball for self-treatment — so good for so many other self-massage jobs — is usually just a little too large and blunt to work here. (It might work on XXL patients.) You could start with a tennis ball just to be more cautious, and it might be satisfying on the side of the paraspinals, which is part of the goal. But to really get a little deeper into that “corner pocket,” you need something a little smaller and more accurate, like a lacrosse ball.
The vulnerability of the thoracolumbar junction
The vertebrae in this area are big, and so are the muscles flanking them. The thoracic spine and rib cage form a heavy and relatively inflexible structure that perches on top of a much narrower and more limber lumbar spine.8 It’s heavily braced by a lot of hard-working muscle tissue.
The 12th thoracic vertebrae often suffers crush and “burst” fractures. The spot is vulnerable because T12 is the lowest of the non-huge vertebrae, making it a weak link in that chain.9 The area is probably often subjected to forces that aren’t severe enough to break anything, but are enough to fatigue and irritate tissues. This may be why trigger points often form here.
About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
- The Trouble with Chairs — The science of being sedentary and how much it does (or doesn’t) affect your health and back pain
- The Complete Guide to Low Back Pain — An extremely detailed guide to the myths, controversies, and treatment options for low back pain
- When to Worry About Low Back Pain — And when not to! What’s bark and what’s bite? Checklists and red flags for the scary causes of back pain
Appendix A: Is trigger point therapy too good to be true?
Trigger point therapy isn’t too good to be true: it’s just ordinary good. It can probably relieve some pain cheaply and safely in many cases. Good bang for buck, and little risk. In the world of pain treatments, that’s a good mix.
But pain is difficult and complex, no treatment is perfect, and there is legitimate controversy about the science of trigger points. Their nature remains somewhat puzzling, and the classic image of a tightly “contracted patch” of muscle tissue may well be wrong. What we do know is that people hurt, and it can often be helped.
The Perfect Spots are based on a decade of my own clinical experience as a massage therapist, and years of extensive science journalism on the topic. Want to know more? This is the tip of the iceberg. I’ve written a whole book about it …
Not too good to be true.
Just ordinary good. Trigger point therapy isn’t a miracle cure, but it is a valuable life skill. Practically anyone can benefit at least a little & many will experience significant relief from stubborn aches & pains. The first few sections are free.
Appendix B: Quick Reference Guide to the Perfect Spots
This index is also available on its own page.
1For headache, neck pain
Under the back of the skull must be the single most pleasing and popular target for massage in the human body. No other patch of muscle gets such rave reviews. It has everything: deeply relaxing and satisfying sensations, and a dramatic therapeutic relevance to one of the most common of all human pains, the common tension headache. And no wonder: without these muscles, your head would fall off. They feel just as important as they are. (Click/tap heading to read more.)
|for pain: almost anywhere in the head, face and neck, but especially the side of the head, behind the ear, the temples and forehead||muscle(s): suboccipital muscles (recti capitis posteriores major and minor, obliqui inferior and superior)|
2For low back pain
This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest rib and your spine — right where the stability of the rib cage and thoracic vertebrae gives way to the relative instability of the lumbar spine. It consists of trigger points in the upper-central corner of the quadratus (square) lumborum muscle and in the thick column of muscle that braces the spine, the erector spinae. (Click/tap heading to read more.)
|for pain: anywhere in the low back, tailbone, lower buttock, abdomen, groin, side of the hip||muscle(s): quadratus lumborum, erector spinae|
3For shin splints
Perfect Spot No. 3 is in your shins — seemingly an unlikely place for muscle knots! But there is meat there, and if you’ve ever had shin splints then you know just how vulnerable that meat can be. Even if you’ve never suffered so painfully, your shins probably still suffer in silence — latent trigger points in the upper third of the shin that don’t cause symptoms, but are plenty sensitive if you press on them. (Click/tap heading to read more.)
|for pain: in the shin, top of the foot, and the big toe||muscle(s): tibialis anterior|
4For thoracic outlet syndrome, throat pain and tightness, chest pain
Deep within the Anatomical Bermuda Triangle, a triangular region on the side of the neck, is the cantankerous scalene muscle group. Massage therapists have vanished while working in this mysterious area, never to be seen again. The region and its muscles are complex and peculiar, and many lesser-trained massage therapists have low confidence working with them. (Click/tap heading to read more.)
|for pain: in the upper back (especially inner edge of the shoulder blade), neck, side of the face, upper chest, shoulder, arm, hand||muscle(s): scalenes (anterior, middle, posterior)|
5For carpal tunnel syndrome, tennis elbow
Just beyond your elbow, all the muscles on the back of your forearm converge into a single thick tendon, the common extensor tendon. At the point where the muscles converge, in the muscles that extend the wrist and fingers, lies one of the more inevitable trigger points in the body: Perfect Spot No. 5. It is constantly provoked both by computer usage today, and more often by the use of a pen in simpler times — and by the occasional tennis match, then and now, or maybe crocheting. (Click/tap heading to read more.)
|for pain: in the elbow, arm, wrist, and hand||muscle(s): extensor muscles of the forearm, mobile wad (brachioradialis, extensor carpi radialis longus and brevis), extensor digitorum, extensor carpi ulnaris|
6For gluteal and hip pain, sciatica, bursitis, low back pain
When you have back pain, buttock pain, hip pain, or leg pain, much or even all of your trouble may well be caused by trigger points in the obscure gluteus medius and minimus muscles, a pair of pizza-slice shaped muscles a little forward of your hip pocket. Other muscles in the region are usually involved as well, such as the gluteus maximus, piriformis, and the lumbar paraspinal muscles. However, the gluteus medius and minimus are a bit special: their contribution to pain in this area is particularly significant, and yet people who have buttock and leg pain rarely suspect that much of it is coming from muscle knots so high and far out on the side of the hip. (Click/tap heading to read more.)
|for pain: in the low back, hip, buttocks (especially immediately under the buttocks), side of the thigh, hamstrings||muscle(s): gluteus medius and minimus|
7For jaw pain, bruxism, headache
Your masseter muscle is your primary chewing muscle — not the only one, but the main one — and it covers the sides of the jaw just behind the cheeks. It’s also the main muscle that clenches your jaw and grinds your teeth, unfortunately, and it’s one of the most common locations for trigger points in the human body. It is probably an accomplice in most cases of bruxism (that’s Latin for “grinding your teeth”) and temporomandibular joint syndrome (jaw joint pain), plus other unexplained painful problems in the area. (Click/tap heading to read more.)
|for pain: in the side of the face, jaw, teeth (rarely)||muscle(s): masseter|
8For runner’s knee
A lot of quadriceps aching, stiffness and fatigue emanates from an epicentre of “knotted” muscle in the lower third of the thigh, in the vastus lateralis, a huge muscle — one of your biggest — that dominates the lateral part of the leg. Stretching it is effectively impossible, but massage is an option: although often shockingly sensitive, Perfect Spot No. 8 can also be quite satisfying. It also often complicates or contributes to other problems in the area, especially runner’s knee (iliotibial band syndrome). (Click/tap heading to read more.)
|for pain: in the lower half of the thigh, knee||muscle(s): quadriceps (vastus lateralis, vastus intermedius, vastus medialis, rectus femoris)|
9For chest pain & tightness
The “pecs” are popular: of 700+ muscles, the pectoralis major is one of just a dozen or so that most people can name and point to. It also harbours one of the most commonly-encountered and significant trigger points in the human body, and can produce pain much like a heart attack in both quality and intensity. (Click/tap heading to read more.)
|for pain: anywhere in the chest, upper arm||muscle(s): pectoralis major|
10For plantar fasciitis
The tenth of the Perfect Spots is one of the most popular of the lot, and right under your feet — literally. It lies in the center of the arch muscles of the foot. This is one of the Perfect Spots that everyone knows about. No massage is complete without a foot massage! (Click/tap heading to read more.)
|for pain: in the bottom of the foot||muscle(s): arch muscles|
11For upper back pain
This “spot” is too large to really be called a “spot” — it’s more of an area. The thick columns of muscle beside the spine are often littered with muscle knots from top to bottom. Nevertheless, there is one section of the group where massage is particularly appreciated: from the thick muscle at the base of the neck, down through the region between the shoulder blades, tapering off around their lower tips. There is no doubt that this part of a back massage feels even better than the rest — even the low back, despite its own quite perfect spots, cannot compete. (Click/tap heading to read more.)
|for pain: anywhere in the upper back, mainly between the shoulder blades||muscle(s): erector spinae muscle group|
12For low back and gluteal pain, sciatica
At the top of the buttocks lies a Perfect Spot for massage: a sneaky but trouble-making brute of a trigger point that commonly forms in the roots of the gluteus maximus muscle. It’s below the lowest part of the low back, but it often feels like low back pain. This is the kind of spot that the Perfect Spots series is all about: not only does it tend to produce a profound, sweet ache when massaged, but the extent of the pain that spreads out around it is almost always a surprise. It feels like a key to much more than expected. (Click/tap heading to read more.)
|for pain: in the lower back, buttocks, hip, hamstrings||muscle(s): gluteus maximus|
13For low back pain, sciatica
Some of the Perfect Spots are perfect because they are “surprising” — it’s delightful to find a place to massage that feels highly relevant your pain in an unexpected location. Others are perfect because they are exactly where you expect them to be — and what a relief it is to be able to treat them. Perfect Spot No. 13 is perhaps the ultimate, the quintessential example of a trigger point that is usually “right where I thought the problem was”: in the “pit” of the low back, at the bottom of the thick columns of back muscle beside the spine. (Click/tap heading to read more.)
|for pain: in the low back, buttocks, hamstrings||muscle(s): erector spinae muscle group at L5|
14For shoulder pain
I avoided adding Spot 14 to this series for many years, because it’s a bit tricky to find. But precision is not required: although there is one specific spot that’s especially good, nearly anywhere under the ridge of bone on the shoulder blade is worthwhile, and often a surprising key to pain and stiffness everywhere else in the shoulder, especially all the way around on the other side, facing forward. (Click/tap heading to read more.)
|for pain: any part of the shoulder, and upper arm||muscle(s): infraspinatus, teres minor|
What’s new in this article?
2017 — Added a lot of substance to the anatomy and function section, supported by several new references.
2016 — Many miscellaneous improvements.
2005 — Publication.
- Takla MKN, Razek NMA, Kattabei O, El-Lythy MAF. A comparison between different modes of real-time sonoelastography in visualizing myofascial trigger points in low back muscles. J Man Manip Ther. 2016 Dec;24(5):253–263. PubMed 27956818 ❐ PainSci Bibliography 53723 ❐
- Phillips S, Mercer S, Bogduk N. Anatomy and biomechanics of quadratus lumborum. Proc Inst Mech Eng H. 2008 Feb;222(2):151–9. PubMed 18441751 ❐ “The magnitudes of the compression forces exerted by quadratus lumborum on the lumbar spine, the extensor moment, and the lateral bending moment, were each no greater than 10 per cent of those exerted by erector spinae and multifidus. These data indicate that quadratus lumborum has no more than a modest action on the lumbar spine, in quantitative terms.”
- If the muscle is full of trigger points, it may painfully resist elevation of the rib cage during inhalation and/or hurt when contracting to pull it down during exhalation. There are several other possible muscular causes of respiratory pain or shortness of breath: see When To Worry About Shortness of Breath … and When Not To.
- Saker E, Tardieu GG, Alonso F, et al. The Forgotten Lumbocostal Ligament: Anatomical Study with Application to Thoracolumbar Surgery. Cureus. 2016 Dec;8(12):e925. PubMed 28090418 ❐ PainSci Bibliography 53722 ❐
- For instance, the quadratus lumborum and lateral erector spinae “wake up” exactly when the rest of the spinal muscles go to “sleep” at the end of a forward bend, a nifty little trick called the “flexion-relaxation phenomenon” (Andersson et al identified the QL activation; see Descarreaux et al for more about the FRP). This actually suggests a good way of checking to see if spot #2 is actually the issue: do a standing forward bend (toe touch). If your low back increases noticeably near the end of it, when the QL and lateral erector spinae are activating … bingo.
- McGill S, Juker D, Kropf P. Quantitative intramuscular myoelectric activity of quadratus lumborum during a wide variety of tasks. Clin Biomech (Bristol, Avon). 1996 Apr;11(3):170–172. PubMed 11415616 ❐ “Electromyographic evidence, together with architectural features make the quadratus lumborum a better stabilizer of the spine than psoas. Use of horizontal 'side support' exercise to train this muscle would appear to be a wise choice.”
- Most of the erector spinae muscles jump from vetebrae to vertebrae, some of the lateral ones — the iliocostalis muscles specifically — span from vetebrae to ribs. They are not generally considered respiratory muscles, because they do not strongly move the ribs: their attachment points are too close to the spine. Nevertheless, when sore and tired, pressure on them clearly seems breathtaking to many patients.
- This is an usual arrangement in nature (few larger animals have a mainly vertical spine). Just because humans have spent a couple million years erect doesn’t mean that we are perfectly adapted to it in every way. What it means is that, in the merciless math of natural selection, the benefits of bipedality outweigh whatever problems it causes us. Evolution is chock-a-block with such trade-offs.
- The L1 breaks less, because it is more massive. T12 breaks instead because, as the lowest of the thoracics, it carries the most weight.