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.
Your “quads” are muscles that people think they know — everyone knows where the quadriceps are, what they’re about, and how to stretch them … right? Actually, they often don’t. The most common misunderstanding concerns stretching. Did you know that it’s actually anatomically impossible to stretch most of the quadriceps?1 Read on to find out why.
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).
A little quadriceps anatomy
Your quadriceps “muscle” is actually a group of three large muscles and one smaller one that merge just above the knee. They are:
- vastus lateralis on the outside of the thigh
- vastus medialis on the inside
- the relatively skinny and insubstantial rectus femoris lying on top, right at the front of the thigh (it is drawn a little too thick and beefy in the diagram here)
- vastus intermedius in the center (hidden underneath the rectus femoris)
The smaller rectus femoris is the only one of the group that crosses both the hip joint and the knee. It powers both of those big joints, whereas the larger three members of the group — the three vasti — only cross the knee and therefore they can only move the knee. One of the most important implications of this (and also one of the best ways to visualize it) is that there is a problem with stretching your quadriceps.
The surprising quadriceps stretching debacle
The traditional quadriceps stretch, which people often call the “runner’s stretch,” stretches only the smaller rectus femoris part of the quadriceps, because that’s the only part of the quadriceps that crosses the hip, which represents roughly 10% of the muscle tissue in the group. Yep, that’s right: probably the most familiar and popular of all stretches is simply missing 90% of the quadriceps muscle mass!
The big underlying trio of vasti muscles is anatomically impossible to stretch strongly, because they elongate only with knee flexion, and knee flexion is strictly limited — you can only flex your knee so far, because the hamstrings are in the way. When you flex your knee, the vasti obviously do elongate — but they don’t elongate much. You will never feel anything like a strong stretch in your thigh by bending your knee … unless you add hip extension into the mix.
But when you add hip extension, you have absolutely no effect whatsoever — zip, zero, zilch — on the vasti, because they simply do not cross the hip, and cannot therefore be affected in the slightest way by hip movements. However, the rectus femoris does cross the hip, and it is already stretched out a bit if your knee is flexed. So, when you extend the hip — as you do in the classic runner’s quads stretch — now you feel a stretch, but the only thing you’re feeling is the rectus femoris.
The bigger quadriceps muscles, with 90% of the quadriceps muscle mass, remain exactly as they were before you added hip extension: they stay modestly elongated by knee flexion, prevented by stretching any further by the collision of your calf with your hamstrings. There is no getting around this! There is no “better” quadriceps stretch that can somehow elongate those vasti muscles. It’s just simple biomechanics — there is simply no such thing as a strong quadriceps stretch.
This quirk of anatomy (which hardly anyone knows about) is just one more reason why I think generic stretching is generally over-rated as a form of exercise. There are too many misconceptions of this type out there!
Where is the perfect quadriceps spot?
Due to its size, the quadriceps group seems to be able to take a licking and keep on ticking. Even when significantly “polluted” by trigger points,2 the quadriceps muscles often still feel mostly fine and functional, and perform as well as needed by the average person, or even by most athletes. This is only true relative to other muscles. Don’t get me wrong — the quadriceps can still be laid low. But seemingly less easily than smaller muscles.
Even when they keep on ticking, a surprising amount of sensitivity to pressure can be lurking in those thick tissues, particularly in the big vastus lateralis muscle. There is a common trigger point there. One of the things that makes Spot No. 8 “perfect” is the tendency it has to be strongly “latent” — that is, to hide in your tissue, unbeknownst to you, until you press on it.
Perfect Spot No. 8 is somewhere in the bottom half of the vastus lateralis muscle, several centimetres from the knee. It’s not on the side of the thigh and not on the top, but between the two — facing forward and out.
In that location, the vastus lateralis can be pressed against the bone underneath. While pressure at virtually any location in the vastus lateralis is likely to feel potent, Perfect Spot No. 8 is a sure thing: with anything more than mild pressure, it is virtually guaranteed to generate that classic “sweet ache” that makes us seek out massage.
Since it isn’t actually possible to stimulate most of the quadriceps muscle group with any kind of stretch, massage is a bit more important.
Does Spot #8 have anything to do with knee problems like IT band syndrome and patellar pain?
The clinical connections between quadriceps trigger points and the “big two” runner’s knee injures — iliotibial band syndrome (ITBS) and patellofemoral syndrome (PFPS) — are probably limited. Those conditions are primarily caused by tissue fatigue at the location of pain. When the tissues are irritated, everything bothers them. When they aren’t inflamed, they can put up with practically anything.
In short, biomechanical factors like grumpy and dysfunctional quadriceps muscles are undoubtedly a factor in these conditions, but they are almost certainly not a major factor.
However, that’s not the conventional wisdom.
The conventional wisdom is pretty sure of itself, and it will tell you that trigger points in the quadriceps matter a lot when it comes to your knee problems. It will tell you that your vastus lateralis is too tight (or your vastus medialis is too weak), which is pulling your kneecap out of whack — a patellar tracking problem — and that’s why you have patellofemoral pain. And it will tell you that your ITB is too “tight” and needs to be “loosened,” and somehow quadriceps massage is going to do that — which is particularly odd, because the quadriceps have no mechanical connection whatsoever to the IT band, so how, exactly, does quadriceps massage loosen the IT band? Hmmm. (Stretching the IT band makes more sense on the surface, and it’s super popular, but doesn’t work well either.)
Perhaps you detect a note of exasperation in my “voice.” All of this conventional wisdom largely ignores the last couple decades of scientific research.
There is a lot of “recent” (up to 20 years old) evidence that all of this conventional wisdom is either wrong or at the least debatable and oversimplified. For instance, researchers have found that people with ITBS don’t have tighter IT bands than anyone else,3 and that therapists and doctors can’t reliably diagnose the existence of a so-called “patellar tracking syndrome,” let alone reliably treat it by any method.4
So, I really wouldn’t make too much of the clinical importance of trigger points when it comes to knee problems. Massage this Perfect Spot (and the rest of your quadriceps) for other reasons — because it feels good, because it relieves a feeling of tension and fatigue in the region. And, hey, the conventional wisdom might not be completely wrong.
Gentle pounding with your fists — the classic Swedish massage technique of tapotement — is also a pretty great way of working this big, meaty muscle group.
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.
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: All the perfect spots
There’s also a more detailed index of the spots and other trigger point resources.
- Massage Therapy for Tension Headaches — Perfect Spot No. 1, in the suboccipital muscles of the neck, under the back of the skull.
- Massage Therapy for Low Back Pain — Perfect Spot No. 2, in the erector spinae and quadratus lumborum muscles in the thoracolumbar corner
- Massage Therapy for Shin Splints — Perfect Spot No. 3, in the tibialis anterior muscle of the shin
- Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain — Perfect Spot No. 4, an area of common trigger points in the odd scalene muscle group in the neck
- Massage Therapy for Tennis Elbow and Wrist Pain — Perfect Spot No. 5, in the common extensor tendon of the forearm
- Massage Therapy for Back Pain, Hip Pain, and Sciatica — Perfect Spot No. 6, an area of common trigger points in the gluteus medius and minimus muscles of the hip
- Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome — Perfect Spot No. 7, the masseter muscle of the jaw
- Spot No. 8 is this page.
- Massage Therapy for Your Pectorals — Perfect Spot No. 9, in the pectoralis major muscle of the chest
- Massage Therapy for Tired Feet (and Plantar Fasciitis!) — Perfect Spot No. 10, in the arch muscles of the foot
- Massage Therapy for Upper Back Pain — Perfect Area No. 11, the erector spinae muscle group of the upper back
- Massage Therapy for Low Back Pain (So Low That It’s Not In the Back) — Perfect Spot No. 12, a common (almost universal) trigger point in the superolateral origin of the gluteus maximus muscle
- Massage Therapy for Low Back Pain (Again) — Perfect Spot No. 13, The Most Classic Low Back Pain Trigger Point
- Massage Therapy for Shoulder Pain — Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain
- Patellofemoral Pain & the Vastus Medialis Myth — Can just one quarter of the quadriceps be the key to anterior knee pain?
- Patellofemoral Tracking Syndrome — The beating heart of the conventional wisdom about patellofemoral pain is mostly nonsense
- Does Hip Strengthening Work for IT Band Syndrome? — The popular “weak hips” theory is itself weak
- And it’s not alone. There are actually quite a few important muscles in the human body that are virtually impossible to stretch. I call them: The Unstretchables.
- Which is a reasonable way of looking at it, as there is intriguing evidence that trigger points are full of waste metabolites: see Toxic Muscle Knots
- Devan MR, Pescatello LS, Faghri P, Anderson J. A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities. J Athl Train. 2004;39:263–267. PubMed #15496997 ❐ PainSci #56601 ❐ For a more detailed analysis of this research, see IT Band & Patellofemoral Pain Defy Common Sense.
- That statement is harder to back up with a single reference, but you can read about it in detail in The Complete Guide to Patellofemoral Pain Syndrome.