updated 5/26/10

Massage Therapy for Low Back Pain

Perfect Spot No. 2, in the thoracolumbar corner

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

Trigger points (TrPs), or muscle knots, are the world’s most common cause of aches and pains, and yet they are rarely diagnosed correctly. Having too many stubborn trigger points is called “myofascial pain syndrome” (MPS). The Perfect Spots series of articles highlights trigger points that are unusually common and yet relatively easy to treat yourself — the most satisfying and therapeutically significant places to apply pressure on the human body. For a complete, advanced tutorial that walks you through every possible self-treatment option for muscle pain, see Save Yourself from Trigger Points & Myofascial Pain Syndrome!

Pain Location	Related Conditions	Related Muscles
anywhere in the low back, tailbone, lower buttock, abdomen, groin, side of the hip	low back pain, herniated disc	quadratus lumborum, erector spinae

“Big Red Books” Reference: Volume 2, Chapter 4

see chart of all spots below

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People usually don’t know about this spot … until it gets massaged! And then it’s like scratching an itch they didn’t even know they had. People say to me, “How could I have not known that was there?” Even when they have low back pain, most people are probably unaware that this spot is the source of so much of it — it often seems too high. But trigger points in this location tend to refer pain downwards, fooling us into thinking our low back pain is lower than it is.

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 gives way to the relative instability of the lumbar spine. Muscle tends to bunch up around this joint between the last of the thoracic vertebrae and the first of the lumbar. The sweet spot 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.

Technically, they are quite different muscles. Practically, trigger points in both will feel like the same spot — Perfect Spot No. 2.

The quadratus lumborum — “QL” for short — is an interesting flat sheet of a muscle, spanning the space between the ribs and the hips. The QL has three major jobs, which is why it often needs work: it acts as a prime mover, a postural muscle, and a respiratory muscle. Some people with back pain also experience significant discomfort when breathing, because a cranky QL resists elevation of the rib cage, and cramps up when pulling it down firmly on exhalation. You can imagine the sense of relief people experience when this is resolved!

The column of paraspinal muscle is not one muscle, but an impressive collection of muscle woven together almost like a thick rope. There is hardly a location anywhere in this muscle group from skull to sacrum that does not have the potential to be someone’s perfect spot … but there is almost always a significant trigger point in the thoracolumbar corner.

How does Perfect Spot No. 2 feel?

Sensation in this area can feel hot and burning if the trigger points are severe, and they can also feel breath-taking, so use caution. However, in the majority of people, a blunted or more gentle pressure will still produce the signature sensation of a Perfect Spot: a deep, “sweet” ache.

You just can’t treat this spot on yourself unless you are unusually flexible or have tools like a tennis ball … but it’s easy to find on someone else. Simply locate the bottom rib, and then work your way inwards towards the spine. Between the bottom rib and about an inch away from the spine is a corner or pocket where you can almost push underneath the rib.

Somewhere in there is the centre of Perfect Spot No. 2, but it may not be obvious at first, because this area is usually so densely populated with significant trigger points that pressure nearly anywhere is going to feel worthwhile. But keep exploring. Using thumbs or fingertips if it’s not too sharp, or an elbow or the heel of the hand for a blunter pressure, slowly push into that pocket, and press inwards and upwards. Keep trying different angles and you are likely to find something really attention-grabbing!

The vulnerability of the thoracolumbar junction

The 12th thoracic vertebrae often suffers crush and “burst” fractures. I’m afraid I have personal experience with this: early in 2010, my wife suffered a serious fracture of this type in Thailand. The spot is vulnerable because T12 is the lowest of the non-huge vertebrae, making it the weak link in the chain. The L1 breaks less, because it is more massive. T12 breaks instead because, as the lowest of the thoracics, it carries the most weight.

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 relieve some pain cheaply and safely in many cases. The existence of trigger points is not controversial. You can measure their electrical activity, take samples of their highly acidic tissue chemistry, and now a new MRI-like technology can now show them as well.

The Perfect Spots are based on a decade of my own clinical experience, and on the research and writing of Drs. Janet Travell and David Simons, pioneers of myofascial pain syndrome research. They produced “the Big Red Books” (a massive pair of texts).

Trigger points are clinically significant, but unfortunately obscure. As Dr. Simons wrote, “Muscle is an orphan organ. No medical speciality claims it.”

Want to know more? This is the tip of the iceberg. There’s a whole book …

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, and many will experience significant relief from stubborn aches and pains. The first several sections are free.

Appendix C: Quick Reference Guide to the Perfect Spots

1Perfect Spot No. 1 — Massage Therapy for Tension Headaches

Under the back of the skull must be the single most popular massage target 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. 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)

2THIS PAGE (Perfect Spot No. 2 — Massage Therapy for Low Back Pain)

Go to top.

3Perfect Spot No. 3 — Massage Therapy for Shin Splints

Perfect Spot No. 3 is in the 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. 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

4Perfect Spot No. 4 — Massage Therapy for Neck Pain, Chest Pain, Arm Pain and Upper Back Pain

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. 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)

5Perfect Spot No. 5 — Massage Therapy for Tennis Elbow and Wrist Pain

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 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. 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

6Perfect Spot No. 6 — Massage Therapy for Back Pain, Hip Pain and Sciatica

When you have back pain, buttock pain, hip pain, 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. 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

7Perfect Spot No. 7 — Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome

Your masseter muscle is your primary chewing muscle, and it covers the sides of the jaw just behind the cheeks. It’s also the muscle that makes you clench your jaw and grind your teeth, unfortunately, and it may be the single most common location for trigger points (muscle knots) in the entire human body. 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

8Perfect Spot No. 8 — Massage Therapy for Your Quads

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 impossible, but massage is an option: although often shockingly sensitive, Perfect Spot No. 8 is often a contributing factor or complication of other problems in the area, especially runner’s knee (iliotibial band syndrome). 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 lateralis, vastus medialis, rectus femoris)

9Perfect Spot No. 9 — Massage Therapy for Your Pectorals

The “pecs” are popular muscles. Of the 700+ muscles in the human body, the pectoralis major is one of the dozen or so that most people can name and point to. It also harbours one of the most commonly-encountered and significant — yet little known — trigger points in the human body, and can produce pain much like a heart attack in both quality and intensity. Read more.

for pain: anywhere in the chest, upper arm

related to: “heart attack,” respiratory dysfunction

muscle(s): pectoralis major

10Perfect Spot No. 10 — Massage Therapy for Tired Feet (and Plantar Fasciitis!)

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! Read more.

for pain: in the bottom of the foot

related to: plantar fasciitis

muscle(s): arch muscles

11Perfect Spot No. 11 — Massage Therapy for Upper Back Pain

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 routinely 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. Read more.

for pain: anywhere in the upper back, mainly between the shoulder blades

related to: scoliosis

muscle(s): erector spinae muscle group

12Perfect Spot No. 12 — Massage Therapy for Low Back Pain (So Low That It’s Not In the Back)

At the top of the gluteal muscles lies a Perfect Spot among Perfect Spots: a sneaky but trouble-making brute of a TrP that commonly forms in the roots of the gluteus maximus muscle, just below the pit of the low back — close enough that most patients describe it as back pain, even though it’s actually in the upper buttocks. It produces a deep ache that spreads throughout the region. This is the kind of spot that the Perfect Spots concept is really all about — not only does it tend to produce a profound and sweet ache when massaged, but the extent of the pain that spreads out around it is almost always a surprise. Read more.

for pain: in the lower back, buttocks, hip, hamstrings

related to: low back pain, sciatica, sacroiliac joint dysfunction

muscle(s): gluteus maximus

13Perfect Spot No. 13 — Massage Therapy for Low Back Pain (Again)

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. Read more.

for pain: in the low back, buttocks, hamstrings