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.
A pain in the butt
And hip. And hamstrings. The deep glutes are a common unsuspected source of pain.
When you have low back pain, buttock pain, hip pain, or leg pain, your trouble might be caused by trigger points in the obscure gluteus medius and minimus muscles. They are a pair of overlapping pizza-slice shaped muscles on the side of the hip. 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 often significant, and yet people who have buttock and leg pain rarely suspect that it might be radiating from muscle knots so high and lateral.
The leg pain that the lateral glutes produce can be so nasty that many health professionals mistake it for sciatica1 (irritation of the large sciatic nerve that passes through the buttocks and into the leg). But beware: sciatica is often an incorrect diagnosis for pain in this area.2
Arthritis is another common scapegoat, but this diagnosis is rarely correct, even in many aging people: most signs of arthritis (on X-ray) are not associated with any pain, and most people who have hip pain definitely do not have arthritis — only 9–15% according to one large study.3 Most hip pain is something else, and muscle pain is a strong candidate, especially when there is no other clear diagnosis.
One trigger point therapy treatment completely relieved a nasty stubborn hip pain that I'd had for five months!
~Jan Campbell, retired French language teacher, Palm Springs, recovered easily from several months of hip pain
What does Perfect Spot No. 6 feel like? Sciatica, among other things
Even without nasty symptoms, pressure on these muscles may still feel important. They usually harbour trigger points that aren’t obvious until they are poked (“latent” trigger points), but which cause symptoms like stiffness, “heavy”-ness, muscle fatigue, vague discomfort and diffuse aching throughout the hip and buttocks and descending into the leg. Their importance is often unsuspected because the key gluteus medius and minimus trigger points are not found where the symptoms are … but they produce symptoms that spread backwards to the sacrum and down the leg.4
Given their stealthy nature, massaging these muscles can feel like a surprising and satisfying discovery of the true source of stiffness you did (or didn’t) know that you had — that’s what makes it a “perfect spot.”
The deltoid of the butt: anatomy and function of the lateral gluteal muscles
The gluteus medius and minimus together are “the deltoid of the butt.” Just as the deltoid muscle lifts the arm out to the side, these lateral glutes lift the leg out to the side: they are “abductors.”
They are small cousins of the more famous gluteus maximus, the big muscle that gives shape to the buttocks (and the home of nearby Perfect Spot No. 12). Medius and minimus are very much a pair, almost one muscle in two parts: they have nearly identical shape, location, and function, both acting as lateral stabilizers, preventing the hips from swinging too far from side to side as you walk and balance. You can activate them easily just by standing on one leg and lifting the other out to the side several times. When you start to feel a burn on the sides of your hips, both of them,5 you are feeling your lateral glutes.
The deltoid of the butt
The gluteus minimus & medius muscles are shaped like slices of pizza. (The minimus is hidden here: it is the same shape as the medius, but smaller & lying directly under it.) Perfect Spot No. 6 is usually found halfway down the lateral edge, right on the side of the hip, in the meaty area between the ridge of the pelvis & the big bone on the side of the hip (greater trochanter). But rather than being “soft,” the edge of the gluteus medius is usually quite rigid — almost as hard as the bones above & below!
These muscles evolved for all-terrain activity, which may be why they cause trouble for many people in the modern world.6
Both the medius and minimus are shaped just like a wide slice of pizza; the points converge downwards on the bony projection on the side of your hip, the greater trochanter at the top of the femur. Their “crust” follows the iliac crest, a bony ridge at the top of the pelvis that defines the waist. The medius completely covers the minimus, and the maximus covers most of the medius — but you can still easily reach these muscles simply by pressing into the soft tissue just below the waist at the side and back.
Where exactly is this perfect spot in the lateral glutes?
As with several of the spots, Perfect Spot No. 6 is actually a small area where you are likely to find a significant trigger point, or several of them. This region of special interest is on the side of the hip and behind it. Or, to use the pizza as a guide, it is roughly the front half of the slice, and especially closer to the tip of the slice.
Start at the big lump of the greater trochanter on the side of the hip — the lower tip of the muscles — and explore up and back from there: all over the side of the hip, right where the seam of your pants would be.
Self-massage tools that are particularly useful on the side of the hip
Trigger points in this area are easy enough to find, but less easy to self-massage. It is a spot that cries out for a massage tool, more so than many other areas: something to trap between your hip and the floor. Tennis ball massage is always a great option for this, of course — and most people already have one around — but there are some other excellent choices as well.
The KONG® dog toy is an amazingly good self-massage tool!
For instance, a KONG® dog toy is a surprisingly useful (and quirky) self-treatment tool for this location; its unusual wedge shape allows you to roll the side of your hip onto it, the pressure increasing as you roll further. This is a difficult (and slightly absurd) procedure to describe, so all I can do is encourage you to take my word for it and experiment. Your dog may get jealous.
Balls and other “pointy” tools are often too intense for the sensitive trigger points in the gluteus medius and minimus muscles. Tubes and rollers fit more naturally into the space between the bones on the side of the hip: you can settle your weight onto them and roll back and forth quite cozily. There are countless foam rollers available — but don’t spend too much, because there are plenty of cheaper and even free improvised options (e.g. pool noodles!). With a foam roller, it’s easier to just settle your weight onto the roller.
Foam rollers work well on the side of the hip.
For a super firm roller, I particularly like the spinal rollers handmade by Allan Saltzman, creator of YogaTools.com — Relieve Tension, Stiffness, and Physical Distortions with Yoga Tools. His spinal rollers are just extremely hard tubes padded with a dense, rubbery foam: simple but very handy, and very sturdy.
Spinal rollers by Allan Saltzman
Allan Saltzman’s simple but sturdy “spinal rollers,” built for the spine but recommended here for the side of the hip. Available at YogaTools.com.
Last but not least, for the best in a pokier self-massage, I recommend The Knobble, a massage tool classic from Pressure Positive.
The Knobble is the best possible tool for applying a focused pressure to a specific spot on the side of the hip. This is the best tool for the long term, once you know where to aim it & have worked your way up to tolerating stronger pressures.
About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
What’s new in this article?
2017 — Science update — Cited evidence of poor correlation between hip pain and radiographic signs of arthritis (Kim et al).
2016 — Added footnote explaining contralateral gluteus medius and minimus action. Added footnote about the poor safety record of hip replacement surgery. Miscellaneous minor edits.
2016 — Miscellaneous editing and improvements. Fixed a few minor errors, moved some details into footnotes.
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 several sections are free.
Appendix B: Quick Reference Guide to the Perfect Spots
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 more inevitable trigger points in the body: Perfect Spot No. 5. It is constantly provoked 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” — 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||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|
- Bewyer DC, Bewyer KJ. Rationale for treatment of hip abductor pain syndrome. Iowa Orthop J. 2003;23:57–60. PubMed #14575251. ❐
Patients with lower back or buttock pain that radiates into the posterior or lateral leg are often referred to physical therapy with a diagnosis of sciatica. Often the physical exam does not reveal neurologic findings indicative of radiculopathy. Instead, there is hip abductor muscle pain and weakness. This syndrome involves muscle imbalances that result in overuse strain of the gluteus medius and gluteus minimus muscles, myofascial trigger points, and trochanteric bursitis. This paper describes hip abductor pain syndrome and provides a rationale for the diagnosis and treatment.
BACK TO TEXT
- The reputation of sciatica is overpowering. Nearly any strong pain in the buttocks or back of the leg is likely to be labelled “sciatica,” even though there are several other possible causes of pain in this area. More about sciatica. BACK TO TEXT
- Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015;351:h5983. PubMed #26631296. ❐ PainSci #53332. ❐
This analysis of thousands of patients confirmed a jarring disconnect between signs of arthritis on hip x-rays and hip pain: “Hip pain was not present in many hips with radiographic osteoarthritis, and many hips with pain did not show radiographic hip osteoarthritis.” What they mean by “many” is “practically all”: roughly 80% of patients with signs of arthritis had no pain, and at least 85% of patients with hip pain had no sign of arthritis! These numbers held up even at the extremes — most older patients with a high suspicion of hip arthritis did not in fact have arthritis that could be diagnosed with an x-ray.BACK TO TEXT
- This is the same phenomenon as the pain of a heart attack spreading into the shoulder and arm (referred pain). In particular, it’s common for referred pain to be strongest right under the butt cheek, which is why it is so often mistaken for sciatica. BACK TO TEXT
- In fact, you’ll ususally feel it more strongly on the side you’re not lifting: the muscles on the stable side are working even harder to close the leg-trunk angle, or to maintain it. Think of it like this: the leg that is swinging outwards can no longer support you, so why don’t you tip over? Answer: the gluteus medius and minimus on the far side, among others, are holding you upright by pulling down on the top of the pelvis. That’s a hard job, and it feels like it. Do thirty right leg raises while trying to stay upright, and you’ll almost certainly notice that your left hip is the one that kacks out first. BACK TO TEXT
- A life lived mostly on the flat and stable surfaces of a city offers little challenge to them, so they are weak and easily exhausted by weekend skiing trips, a walk on the soft sand of a beach, or really anything that requires more balancing than usual. The combination of chronic mild weakness with erratic stressful challenges may be the reason they tend to get polluted with trigger points. And this is all just an educated guess. It’s unknown why individual trigger points come and go. I discuss the trouble with running on flat surfaces in Is Running on Pavement Risky?. BACK TO TEXT
- Harris I. Surgery: The ultimate placebo. NewSouth Publishing; 2016. “Total hip replacement surgery for arthritis is generally considered a very effective operation in achieving pain relief and restoring function, even though it has never been subjected to randomized trial” — literally unproven medicine, despite being on the most popular surgeries in the history of surgery, with a scandalous recent history: the “metal-on-metal” disaster, starting in 2005. MoM “just sounded better” but proved to have serious unintended consequences caused by the release of metal ions. See “How safe are metal-on-metal hip implants?” Extremely unsafe!BACK TO TEXT