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.
Deep within the Anatomical Bermuda Triangle, a 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 less-trained massage therapists have low confidence working with them. This article explains how the scalene muscles are involved in several common pain problems in the neck, chest, arm, and upper back, and how to treat pain in these areas by massaging the scalenes. The scalenes are a difficult muscle group to work with, but rewarding!
The scalenes are often involved in common neck pain and headaches, but that's just the tip of the iceberg. Seriously, this is a weird area: the scalenes often harbour TrPs with more diverse and peculiar symptoms than any other muscle tissue in the body. The primary mechanism for this strangeness is the phenomenon of “referred pain.” Pain in the scalenes is often felt just about anywhere but the scalenes themselves. Instead of your scalenes, your arm or chest might hurt instead.1
Referred pain effects are par for the course with all muscle pain or any other internal pain — for instance, heart attacks are felt in the shoulder and arm — but the scalene muscles consistently produce unusually complex, variable, and extensive patterns of referred pain. The results can be a bit bizarre, causing symptoms that most people never guess are coming from the scalenes, even doctors and therapists.
And scalene TrPs can also have several other “interesting” (in the sense of the Chinese curse2) effects: on your voice, on swallowing, on emotions, on sensations that sweep through the entire head, the sinuses, hearing, and teeth. I have found scalene TrPs to be obviously clinically relevant to conditions as seemingly unrelated as:
So scalene trigger points are “drama queens,” with symptoms and consequences that seem out of proportion to such small and obscure muscles. They often contribute to anything else that goes wrong in the whole region. Like a gang, scalene TrPs can be counted on to mess up the neighbourhood. The anterior scalene in particular is a trouble-maker, causing and complicating many other problems.
The scalenes fan out from the sides of the neck bones to attach to the ribs, above the collarbone.4 The scalene group consists of three muscles: the anterior, middle, and posterior scalenes. They generally attach to the sides of the neck vertebrae at the top and to the uppermost ribs at the bottom. So the scalenes are mostly head pullers: they pull the head from side to side. And although they certainly do move the neck, they are also breathing muscles, because of the way they pull up on the ribs.
And here’s some more weirdness that makes this muscle group quite interesting: in some people the scalene muscles even reach down between the ribs and attach directly to the top of the lungs, In some people the scalene muscles even reach down between the ribs & attach directly to the top of the lungs. the only muscles that attach directly to the lungs other than the diaphragm. They pull up on the pleura, the membrane that shrink-wraps the lungs. A strange muscle group indeed! Such anatomical variability is actually fairly common throughout our bodies.5
The scalenes as a group are not hard to find, but they are intricate in their details. They fill the space between three obvious structures that form the triangle:
Perfect Spot 4 is somewhere in the triangle. There is one particular spot, in the belly of the middle scalene, that I think is the most common clinically significant trigger point — the spot most likely to feel important patients — but I don’t want to send you on a wild goose chase trying to locate exactly that spot. Any location within the triangle could prove to be important, so you should definitely explore. Things change, too: Perfect Spot 4 might be in one corner of the triangle one day, and in another corner the next. Precise self-treatment isn’t necessary — a willingness to gently experiment is.
The best way to approach this area as a helper is from above the head, with the recipient face up. Without a massage table, it works well to place his or her head in the corner of a bed. Hold your fingers flat and place the pads of your fingertips in the hollow of the triangle: above the collarbone, in front of the massive trapezius muscle along the top of the shoulder, and on the outside of the prominent V-shaped sternocleidomastoid muscles of the throat.
In this position, your hands will be angled inward a bit, and roughly pointing at the sternum. Now press down and perhaps a little inwards with a fairly broad pressure — finger pads, not finger tips — on the ropy muscles that fill the triangle. By using a broad pressure, you can easily stimulate some TrPs and stiff muscle without having to worry about being too accurate.
Explore in the triangle with your fingertips, using small circles to find the ropy bands of muscles, gently strumming across them. The area is a rich minefield of trigger points, any of which might be worthwhile and interesting.
Massage feels better on some muscles than others.6 The scalenes are not really pleasurable to massage, in general. The throat is a vulnerable body part, so many people feel threatened by pressure here — beware of underestimating it,7 and all the more so if you aren’t confident that massage is safe, or if you don’t understand the strange sensations that are so common in this area. That vulnerability seems to translate into sensitivity, so even a gentle approach may feel a bit hot, nasty, and dodgy at first — not really the kind of trigger point you want to mess around with for fun.
Wow, sign me up! Sounds great, doesn’t it? But it’s not all bad news.
Some people enjoy scalene massage right out of the box, and others can come to appreciate it after a period of “working through” and getting used to the uglier sensations. But the best case scenario is when you are actually solving a problem: if your scalenes are in distress and causing a chronic pain problem, then it’s going to feel more like you’re finding the right place to scratch an itch that you couldn’t reach before.
Maximize your chances of a positive experience by moving slowly and respectfully, and massaging the scalenes with broader, less “poky” pressure. Such pressure is more likely to produce the best case scenario: a peculiar deep ache spreading into the head, chest, back, and/or arm. At its best, scalene massage feels challenging but “profound.” The spectacular referral patterns make the scalenes feel important, the key to the region. As an entire limb “lights up” with referred pain from a light pressure in the neck, many people will say something like, “Holy $%!@$#$!, what the hell is that?” No muscle produces more amazed comments. As an entire limb “lights up” with referred pain from a light pressure in the neck, many people will say something like, “Holy $%!@$#$!, what the hell is that?” This is generally true of all referred pain, and it’s equally true of all the Perfect Spots, but “some trigger points are more equal than others.” The scalenes may be awkward and uncomfortable to massage at first, but this Perfect Spot can be very impressive in the end.
So be prepared for anything, and take it easy.
Although you might have to “work through” a little unpleasant sensation to get to the better sensations, this doesn’t mean “no pain, no gain” — do not be brutal in this area. Patients need a little time to adjust and “accept” the stimulation in this area. Persist respectfully, and there is a fair to middling chance that the sensation will change from hot to warm, from sharper to achier. It might make the transition in five minutes, or it might take a few days of sweet-talking the area. But there is a reasonable limit to how much you should try. If the effort doesn’t start to develop a bright side after a reasonable amount of time, then this Perfect Spot isn’t so perfect, and you should let it go.
Many common aches and pains, particularly around the head, neck and shoulders, may be caused in part by inefficient breathing. It’s just a theory, but the connection between dysfunctional breathing and pain is straightforward in principle: if the diaphragm doesn’t do its job well, muscles in the upper chest (pectoralis minor) and throat (sternocleidomastoid and scalenes) try to take over. Unfortunately, these muscles just aren’t built for routine respiration, and they can exhaust themselves to the point of irritation and injury. A cascade of consequences may result, from garden variety stiffness to seemingly unlikely and severe consequences such as rotator cuff injuries, whiplash and thoracic outlet syndrome — a constellation of painful upper body conditions.
And the strange, cranky scalenes are the most likely muscles to cause symptoms in this scenario.
For more information, see The Respiration Connection.
If it exists, the connection between dysfunctional breathing and pain is straightforward in principle: if the diaphragm doesn’t do its job well, muscles in the upper chest (pectoralis minor) and throat (sternocleidomastoid and scalenes) try to take over. Unfortunately, these muscles aren’t built for routine respiration, and they exhaust and eventually injure themselves. A cascade of potential consequences results.
Anything that makes breathing more difficult could easily provoke over-use of the scalenes. There are many possibilities, but probably the most common and preventable is smoking — which is also risk-factor for chronic pain independently,8 so it’s a double whammy. This is pure speculation, but smokers could not only have more trigger points in their accessory respiratory muscles, but nastier ones, more painful and persistent.
This tennis elbow connection is a good example of how odd and clinically relevant the scalenes can be to conditions they don’t seem to have anything to do with at first.
The scalene muscle group has surprising importance to a condition called “tennis elbow” or lateral epicondylitis, which commonly afflicts typists as well as racquet sports players. It is generally characterized as an inflammatory condition, but it is rarely that simple.9 It is likely that myofascial TrPs, particularly Perfect Spot No. 5 in the muscles of the forearm, play a significant role in any case of tennis elbow.
And Perfect Spot No. 4 seems, in turn, to significantly affect Perfect Spot No. 5. Travell and Simons write, “Scalene muscle trigger points are frequently the key to [treatment of] forearm extensor digitorum trigger points.” That is, trigger points on the back of the forearm.10 So an interesting benefit to treating Perfect Spot No. 4 is that it may be a key to treating Perfect Spot No. 5!
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.
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 …
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||related to: headache, neck pain, migraine||muscle(s): suboccipital muscles (recti capitis posteriores major and minor, obliqui inferior and superior)|
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||related to: low back pain, herniated disc||muscle(s): quadratus lumborum, erector spinae|
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||related to: shin splints, drop foot, anterior compartment syndrome, medial tibial stress syndrome||muscle(s): tibialis anterior|
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||related to: thoracic outlet syndrome, lump in the throat, hoarseness, TMJ syndrome||muscle(s): the scalenes (anterior, middle, posterior)|
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 most inevitable myofascial TrPs in modern civilization: Perfect Spot No. 5. It is constantly and greatly aggravated both by computer usage today and by the use of a pen in simpler times — and by the occasional tennis match, then and now. (Click/tap heading to read more.)
|for pain: in the elbow, arm, wrist, and hand||related to: carpal tunnel syndrome, tennis elbow (lateral epicondylitis), golfer’s elbow (medial epicondylitis), thoracic outlet syndrome, and several more||muscle(s): extensor muscles of the forearm, mobile wad (brachioradialis, extensor carpi radialis longus and brevis), extensor digitorum, extensor carpi ulnaris|
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||related to: sciatica, trochanteric bursitis, low back pain||muscle(s): gluteus medius and minimus|
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)||related to: bruxism, headache, jaw clenching, TMJ syndrome, toothache, tinnitus||muscle(s): masseter|
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||related to: iliotibial band syndrome, patellofemoral pain syndrome||muscle(s): quadriceps (vastus lateralis, vastus intermedius, vastus medialis, rectus femoris)|
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||related to: “heart attack,” respiratory dysfunction||muscle(s): pectoralis major|
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||related to: plantar fasciitis||muscle(s): arch muscles|
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||related to: scoliosis||muscle(s): erector spinae muscle group|
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||related to: low back pain, sciatica, sacroiliac joint dysfunction||muscle(s): gluteus maximus|
Some of the Perfect Spots are perfect because they are “surprising” — they aren’t where you thought they’d be, and it’s delightful to discover the real source of pain. 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 “right where I thought it was” trigger point: right at the very bottom of the thick columns of muscle, in the “pit” of the low back. (Click/tap heading to read more.)
|for pain: in the low back, buttocks, hamstrings||related to: low back pain, sciatica, sacroiliac joint dysfunction||muscle(s): erector spinae muscle group at L5|
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||related to: frozen shoulder, supraspinatus tendinitis||muscle(s): infraspinatus, teres minor|
— Edited for clarity.
— Miscellaneous improvements.