Trigger points (TrPs), or muscle knots, are a common cause of stubborn and strange aches and pains, and yet they are under-diagnosed. The 14 Perfect Spots (jump to list below) are trigger points that are common and yet fairly easy to massage yourself — the most satisfying and useful places to apply pressure to muscle. For tough cases, see the advanced trigger points treatment guide.
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.
Amaze your friends! It’s one thing to massage a Perfect Spot in a familiar location for pain and stiffness, like under the back of skull, but it’s a bigger treat to reveal one where none was even suspected. Confusion about where the pain is coming from is always a feature of this spot. When it’s active, people usually assume they need a back rub. “My back hurts,” they say, as they point right at the top of their buttocks. “You know, that’s not actually your back — that’s your butt,” I say. People often don’t consciously realize that it’s their buttocks that are the problem until you actually press on the spot — but then they clearly recognize it as the epicentre of tension in the region. What’s going on?
Gluteus maximus is a massive muscle. Along with the quadriceps, it’s known as an “anti-gravity” muscle for its powerful lifting action. Your gluteus maximus is heavily recruited for stair climbing and jumping. Trigger points in big muscles can be sneaky: they seem to tolerate more knotting up before you start to notice a problem. A vague feeling of fatigue, stiffness, and heaviness in the area can get well-established long before it actually starts to hurt. This may explain why hardly anyone seems to know about this spot until it is massaged.It can be a great relief to know that so much sensation is not associated with the spine.
Spot 12 feels like a safe spot to rub. Like all the Perfect Spots, Spot No. 12 is in an extensor muscle. Muscle knots in muscles that open the body (extensors) tend to feel satisfying and safe, producing a “sweet” ache instead of sharp or burning quality.1 Not only is gluteus maximus a big ol’ extensor, it’s also located in what is arguably one of most sturdy and least vulnerable places in the human body. The buttocks are well-padded, with muscle and at least some fat in almost everyone, and they cover the largest bony structures in our skeleton.
This is all meaningful in the context of low back pain, because low back pain spooks people. Most low back pain patients fear that their pain is related to structural problems and spinal fragility — unncessarily.2 Not only is the spine extremely sturdy and the bark of low back pain far worse than its bite, much of the pain is also often radiating from lower down — from the nearly indestructible gluteus maximus.
The single best thing anyone can do for most back pain patients is to reassure them, and Perfect Spot No. 12 is reassuring: it feels like it has strong relevance to the back pain, and yet it’s radiating from the meaty depths of this sturdy region of pure muscle and bone. It’s a “safer” feeling discomfort. It can be a great relief to know that so much sensation is not associated with the spine.
The gluteus maximus is a large muscle, and contains a several good spots for massage. Perfect Spot 12 is the best by far, however: near the top, along the thickened edge (superolateral) where the gluteus maximus attaches to the pelvic bone. It’s easy to find: just look for the low back dimples! Or, if you are working on someone without low back dimples, you’ll have to go by feel. The dimples mark the location of a pair of distinct bumps of bone on either side of the extreme low back, about an inch or two away from the spine.3
Once you’ve found the dimples and/or the bumps of bone, you’re practically there. The gluteus maximus is attached to the bottom edge of that bump. Strum your fingers back and forth (side to side) just below the bump to find a thick bundle of muscle, angling down and away from the dimple. That’s the edge of the gluteus maximus! The best place to press on it is usually about a centimetre below the bone. The best angle is usually pressing from the side, like you want to push the muscle towards the tailbone.
Perfect Spot No. 12 often feels like deep, aching back pain.
At least half of low back pain has a large component of buttock pain.4 I call this the “butt-back connection.” The top of the pelvic bone, the iliac crest that defines the bottom of the waist, sharply divides the back from the buttocks. No muscles cross that line of bone. Yet the gluteus maximus is in many ways a functional extension of the back muscles, and vice versa — they work together, and they seem to suffer together.
The most significant TrPs of the back muscles (Perfect Spot No. 13, next in the series), are just an inch or two away on the other side of the back dimples, at the lowest point in the low back. Trouble in either Spot tends to go with the other. Strong TrPs at Perfect Spot No. 12 radiate a deep, back-aching sensation both downwards through the buttocks and upwards into the low back. The low back TrPs return the favour. TrPs in the gluteus medius and minimus (see Massage Therapy for Back Pain, Hip Pain, and Sciatica) also often contribute to this unholy region of sensitive soft tissue. (Although they tend to produce more leg pain than back pain, their symptoms are often mistakenly believed to be a symptom of nerve root compression in the back, or sciatica.5)
Less experienced back massagers will often miss this spot. It looks too low to have anything to do with the back. Many people will rub only in the low back itself, finding plenty of stiff and sore muscles, yet somehow failing to fully satisfy their patient, who will probably feel like the massage isn’t going quite low enough. Even if directed to move lower — which doesn’t always happen, because most patients lack the confidence to redirect the massage into the buttocks — the therapist may still not get to the source of the trouble, because Perfect Spot No. 12 is lurking right around a projection of bone and does not seem a likely place for important work. Yet that is often exactly what’s needed.
When Perfect Spot No. 12 isn’t being mistaken for back pain, or contributing to false sciatica, it’s getting mistaken for sacroiliac joint pain (resulting in a nearly perfect record of being mistaken for anything other than what it is). The confusion arises because many professionals focus too much on the importance of subtle sacroiliac joint problems, as though the slightest problem here can wreak havoc.
The sacroiliac joint is a barely-mobile joint between the pelvis and the sacrum, which can rotate only a couple degrees and slide only a couple millimetres.6 It’s one of those joints that patients have been taught to worry about by therapists, but sacroiliac joint pain and dysfunction is seriously over-rated and over-diagnosed, particularly by massage therapists and chiropractors, most of whom cannot reliably detect alleged alignment problems7 or change the joint position even if they could.8
Problems with this joint undoubtedly do exist. It’s affected by inflammatory back pain,9 and it can be injured, of course. It fuses in many of us with age — it doesn’t move at all in half of 80-year-olds, especially men.10 — which isn’t necessarily painful, but probably is uncomfortable in some cases. But a lot of alleged sacroiliac joint pain is probably just the discomfort associated with Perfect Spot No. 12 — and it’s safe, easy, and cheap to test that theory with some experimental massage.Perfect Spot No. 12 has a nearly perfect record of being mistaken for anything other than what it is!
Consider this typical case study, one many similar cases I’ve seen: One of my patients spent a few years with chronic moderate-intensity pain in her hip and/or low back. She was never quite sure which, true to the nature of a gluteus maximus TrP. She also believed (fervently) that it was a sacroiliac joint problem, and this had been affirmed repeatedly by therapists, so her belief was strong. However, it turned out that just a little pressure on Perfect Spot No. 12 was lastingly helpful, whereas years of “adjustments” for a non-existent sacroiliac joint problem had simply failed her. Here’s what I heard from her months later:
Just wanted to give you a quick update … my back has been absolutely fine. Unbelievable … or perhaps not, considering what I’ve learned from you! A big thank you for all your help.
Lois McConnell, retired airline executive, suffered chronic low back and hip pain for a few years
Although the quality of sensation in Perfect Spot No. 12 is usually among the deepest, most aching, and most relieving of all trigger point sensations in the body, about 25% of the time it can be sharper and hotter and not so pleasant. This is particularly true when the pressure is applied closer to the dimple/bump. This less satisfying feeling usually indicates either that the pressure is too much on the tendon, and you can move a little further down into the muscle proper (probably only a few millimetres) to get to the “good pain” — or it indicates a particularly tetchy TrP, and there’s nothing to be done except work through it slowly and gently.
The pressure tolerance of this spot varies widely from person to person — true of every trigger point, but once again Perfect Spot No. 12 is an especially good example. For those who have suffered low back pain or work in a chair, this spot may be extremely sensitive and require only gentle pressure with the tip of a finger. Others may easily tolerate your entire body weight delivered through the point of your elbow. Start gently, and slowly work your way up to the desired pressure.
Finally, on a scary note, when Perfect Spot No. 12 persists in the gluteus maximus for long enough, it can really do some damage.11
In 2006, researchers in Taiwan scanned some “tight asses” with an MRI machine. Specifically, they studied people with gluteus maximus contracture.12
“Contracture” is a kind of über tightness in which muscle that has been tight for too long essentially freezes in place, just like your mother warned would happen to your face if you kept making ugly faces.
The MRIs showed that contracture causes your gluteus maximus to form a tough, fibrous, ropy band of muscle, while the rest of the muscle atrophies. Also, the tightness of the muscle pulls the IT band backwards (which can be an important factor in a common runner’s knee problem, iliotibial band syndrome).
Can you tell yourself if you’re contractured? It’s difficult to confirm the presence of contracture by touch alone, but the more obvious the ropy texture, the more likely it is to be contractured.
Dealing with contracture is a tricky business, perhaps almost impossible — even hard stretching will probably have no effect.13 Once a muscle like the gluteus maximus is contractured, TrP release becomes much more difficult. If you already have a very hard, ropy band of muscle in your gluteus maximus, you may get some relief from stimulating Perfect Spot No. 12 … but it probably won’t last very long.
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|
— More editing for clarity. Added much more detail (and science) about the sacroliac joint.
— Revised the first few hundred words for clarity.
BACK TO TEXT
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.
This review of seven good quality studies of sacroliac joint movement found that it is “limited to minute amounts of rotation and of translation.” Specifically, there’s a maximum of about 8˚ rotation and 8mm translation, which might sound like more than a “minute” amount, but those are very specific maximums. The “average” motion would be much less, just a couple degrees and millimetres in most cases. According to this data, it’s probably difficult and unreliable for therapists to determine SIJ movement and position by feel.BACK TO TEXT
BACK TO TEXT
This study of 287 people showed that the sacroliac joint fuses with age, to the point where nearly half of subjects over 80 no longer had a joint there. Also, there was a dramatic gender split: almost 30% of the men were fused, but only 3% of the women.BACK TO TEXT