updated 10/17/09

Massage Therapy for Low Back Pain

Perfect Spot No. 2, in the thoracolumbar corner

by Paul Ingraham, Registered Massage Therapist, Vancouver, Canada

Trigger points (muscle knots) are the world’s most common cause of aches and pains. The Perfect Spots series of articles teaches you how to self massage the most satisfying and therapeutically significant places on the human body to apply pressure. Each Perfect Spot article focuses on a specific location. 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!

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.

Perfect Spot No. 2 lives in the “thoracolumbar corner,” which is formed between your ribs and your spine — right where the stability of the rib cage gives way to the relative instability of the lumbar spine. Muscle tissue tends to bunch up around the joint between the 12th thoracic and the 1st lumbar vertebra. 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, 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!

All The Perfect Spots for Trigger Point Massage

Choose your perfect spot!

Or, for general information and advanced tips about trigger point therapy, see Save Yourself from Trigger Points!

and …

All the Spots — An extremely detailed tutorial filled with advanced troubleshooting tips, perfect for any Perfect Spot!

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Are trigger points too good to be true?

Trigger point therapy often fails, but it often succeeds. Trigger points are not a “flaky” diagnosis. They are based on a lot of hard science. You can take photomicrographs of them, measure their electrical activity, take samples of their acidic and toxic tissue chemistry.

In addition to a decade of my own clinical experience, the Perfect Spots are based primarily on the research and writing of Drs. Janet Travell and David Simons, the pioneers of myofascial pain syndrome research. Dr. Travell died in 1997 after decades of tireless efforts to educate her medical colleagues about trigger points. Dr. Simons continues to publish. They produced “the Big Red Books,” a massive 2-volume text about trigger points, and recently Dr. Simons published Muscle Pain with Dr. Siegfried Mense.

Travell et al. Myofascial Pain and Dysfunction. 1999.
Mense et al. Muscle Pain. 2000.

The existence and importance of trigger points is not scientifically controversial, but it is obscure. The challenge is to get the word out. Doctors are generally uninformed about musculoskeletal health care — it simply isn’t on their radar. As Dr. Simons wrote, “Muscle is an orphan organ. No medical speciality claims it.