Detailed, evidence-based help for common painful problems

Massage Therapy for Low Back Pain (Again)

Perfect Spot No. 13, The Most Classic Low Back Pain Trigger Point

PAGE INFO updated  by Paul Ingraham
Word count: 1,700
Reading time: 7 minutes
Published: 2007

Citations: ~5
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.

Important! This article is meant for people with a minor low back pain. If you are having serious or chronic back pain, please start with: Complete Guide to Low Back Pain

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.

How do you find Perfect Spot No. 13?

Anatomy of the lower back, superficial dissection, with a blue circle in the low right back, highlighting the recommended location for massage (described in detail below).

Perfect Spot No. 13 is easy to find. Think of the “pit” of your low back: the bottom of the back, as far down as you can go, right next to the spine, without actually crossing over into the pelvis. It is the lowest possible spot next to the spine that can still be called the back.

“Low back pain” is felt anywhere from the sides of the hips to the tips of the lower ribs. Perfect Spot No. 13 is at the geographic center of the possibilities, right between the back dimples.

If you press on the meaty column of muscle found on either side of the spine — the lumbar paraspinal muscles or the erector spinae muscle group — and follow it downwards, you will find that the last place where it feels thick and meaty is between the low back dimple and the spine. Go any lower and the muscle feels thinner as it peters out and starts to turn into tendon and gristle over the surface of the sacrum.

Perfect Spot No. 13 is usually right beside the dimple, in the lowest thick segment of the paraspinals. It might also be found slightly higher, or slightly lower in the thinner tissue over the sacrum.

A more anatomical way to think of the location

There’s a diamond-shape layer of tough connective tissue across the entire low back, the thoracolumbar fascia.show This structure may get thickened and stiff in people with back pain.1 Perhaps not coincidentally, Spot #13 is right smack dab in the bottom tip of it, where it is sturdiest and “anchors” to the pelvis and lowest part of the spine.

What does Perfect Spot No. 13 feel like?

In most people with back pain, pressure on this spot feels like a deep, deep, deep dull ache that closely resembles any back pain or stiffness that you may have in the area. That is, pressure “reproduces” the quality of pain of many a back ache.2

One of the reasons that I’ve nominated this trigger point to be a Perfect Spot is that, properly located and treated, it so reliably feels like scratching an itch — one of the best examples of that feeling to be found anywhere in the body.

This is a sturdy part of any back, assuming it’s not in some kind of serious trouble. For many people, mild and moderate pressure will not scratch the itch. It may take surprisingly firm pressure to trigger the feeling that makes you want to say, “Oh yeah, that’s it, right there!” If firm pressure causes strong and unpleasant pain, back off, of course: it’s not a perfect spot for you, and it’s even possible that your system is protecting itself from disturbance of a structural abnormality.3

Confusion with Perfect Spot No. 12

If you’ve read the whole Perfect Spot series, you might notice that Spot 12 is rather close to this one. They are just on either side of the “divide” of the upper ridge of the pelvic, 12 in the gluteals, 13 in the low back, no more than an inch or two apart.

Almost anyone who likes pressure on one is going to crave it on the other (the “butt-back connection”). However, one of them usually feels more obviously like the epicentre of pain and/or stiffness in the region. Check both!

How do you treat Perfect Spot No. 13?

Start with thumbs — but this is deep muscle tissue, and often you (and your patient) are going to want to graduate to elbow. It’s an easy spot to press on with the elbow, and many people absolutely require a good portion of your body weight delivered in this way in order to get relief.

Sometimes pressure is best applied straight downwards onto the back muscles here. But for many people, the trigger point is better treated with a pressure that is direct partly downwards, and partly on an angle towards the spine. In some cases, you may even find that the best relief comes from attack the spot directly from the side, pressing horizontally into the very side of the muscle group, straight towards the spine.

The further you move around to the side, the more you generally have to navigate upwards (towards the head) a smidgen, which actually puts your point of contact above the low back dimple, as opposed to between the dimple and the spine. This is okay. Perfect Spot No. 13 is in there somewhere in that lowest section of lumbar paraspinal muscle; feel free to experiment with many angles. Anything within a few square centimetres down there counts as being Spot No. 13.

This is also a good spot for massage tools, because of the toughness of the tissue. A smaller, harder ball like a lacrosse ball is ideal. Start by pinching the ball between your back and wall, squatting a bit and leaning into it, and roll up and down and back in forth in short strokes.

A trigger point success story

Reader Alex B. send me a good anecdote about his rapid recovery from sciatica by treating muscles “knots” in his low back and upper gluteals:

Recently, seemingly overnight, I developed what appeared to be femoral neuropathy caused by a benign tumour (neurofibromatosis). I seemed to have some regular "sciatica" too. I spent months getting MRIs, going to chiropractors and physical therapists, with no relief. A surgeon told me to just accept that the tumour was the cause of the pain, but I didn't believe him: a giant neurofibroma could surely cause pain, but I figured it would have been a slow build rather than overnight.

Anyway, I finally found your website. Sure as shit, I did the perfect spot #12 and #13 for one night — just a single dose — and I was 95% healed. It's been 8 months since I could walk without a limp and I swear to god I am able to sprint again. I was doing flips into a pool this weekend!

I followed up with Alex a couple weeks later and confirmed that he was still doing well. anecdotes are not evidence, of course, but stories like this are quite common in my experience.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

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

Picture of the cover of my ebook, Save Yourself from Trigger Points and Myofascial Pain Syndrome.

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.

  1. Massage Therapy for Tension Headaches — Perfect Spot No. 1, in the suboccipital muscles of the neck, under the back of the skull.
  2. Massage Therapy for Low Back Pain — Perfect Spot No. 2, in the erector spinae and quadratus lumborum muscles in the thoracolumbar corner
  3. Massage Therapy for Shin Splints — Perfect Spot No. 3, in the tibialis anterior muscle of the shin
  4. 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
  5. Massage Therapy for Tennis Elbow and Wrist Pain — Perfect Spot No. 5, in the common extensor tendon of the forearm
  6. 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
  7. Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome — Perfect Spot No. 7, the masseter muscle of the jaw
  8. Massage Therapy for Your Quads — Perfect Spot No. 8, another one for runners, the distal vastus lateralis of the quadriceps group
  9. Massage Therapy for Your Pectorals — Perfect Spot No. 9, in the pectoralis major muscle of the chest
  10. Massage Therapy for Tired Feet (and Plantar Fasciitis!) — Perfect Spot No. 10, in the arch muscles of the foot
  11. Massage Therapy for Upper Back Pain — Perfect Area No. 11, the erector spinae muscle group of the upper back
  12. 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
  13. Spot No. 13 is this page.
  14. Massage Therapy for Shoulder Pain — Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain

What’s new in this article?

2017 — Miscellaneous improvements. Finally added a diagram!

2007 — Publication.

Notes

  1. Langevin HM, Fox JR, Koptiuch C, et al. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskelet Disord. 2011 Sep;12:203. PubMed #21929806 ❐ PainSci #53517 ❐
  2. The sensitivity a trigger point will often feel “like” a problem that has been bothering you, or has bothered you in the past. It will feel accurate (located in what seems like the right spot to you), relevant to the problem (related or connected to it in some way that may or may not be obvious), or simply similar to a symptom you’ve been having. This “recognition” factor is a standard diagnostic criteria for trigger points (see Gerwin 1997). It’s characteristic of all of the perfect spots, but often particularly strong with Spot #13.
  3. For instance, spondylolisthesis is a dislocation of vertebral joint, when one vertebra slides forward over the one below it. Many people don’t even know that this is going on, and it may even be entirely painless. But direct, firm pressure on or near the joint could feel weird and/or bad!