Pressure Positive makes practical trigger point self care tools. See www.PressurePositive.com.

[Image: diagram of anatomical bermuda triangle, a region of intriguing musculature, especially the scalene muscle group with its common and clinically significant myofascial trigger points.]

Trigger points in this area cause an astonishing array of problems in the neck, head, chest, back, and arms!

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 peculiar scalene muscle group of the throat

2,400 words, updated Jun 15th, 2012
by Paul Ingraham, Vancouver, Canada
illustrations by Paul Ingraham, Gary Lyons, Jim Smith, Elizabeth Boylan

Trigger points (TrPs), or muscle knots, are a common cause of stubborn and strange aches and pains, and yet they are under-diagnosed. The 13 Perfect Spots 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 treatment guide.

Pain Location	Problems	Related Muscles
in the upper back (especially inner edge of the shoulder blade), neck, side of the face, upper chest, shoulder, arm, hand	thoracic outlet syndrome, lump in the throat, hoarseness, TMJ syndrome	the scalenes (anterior, middle, posterior)

“Big Red Books” Reference: Volume 1, Chapter 20

see chart of all spots below

Deep within the Anatomical Bermuda Triangle, a 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 less-trained massage therapists have low confidence working with them. This article explains how the scalene muscles are involved in several common pain problems in the neck, chest, arm, and upper back, and how to treat pain in these areas by massaging the scalenes. The scalenes are a difficult muscle group to work with, but rewarding!

“It’s my hand, doc. My hand hurts.”

“It’s my hand, doc. My hand hurts.”

The scalenes are a strange muscle group

Seriously, this is a weird area: the scalenes often harbour TrPs with more diverse and peculiar symptoms than any other muscle tissue in the body. The primary mechanism for this strangeness is the phenomenon of “referred pain.” Pain in the scalenes is often felt just about anywhere but the scalenes themselves. Instead of your scalenes, your arm or chest might hurt instead.1

Referred pain effects are par for the course with all muscle pain or any other internal pain — for instance, heart attacks are felt in the shoulder and arm — but the scalene muscles consistently produce unusually complex, variable, and extensive patterns of referred pain. The results can be a bit bizarre, causing symptoms that most people never guess are coming from the scalenes — even doctors and therapists.

[Diagram showing areas of pain referred from the scalene muscle group. This diagram shows the possible involvement of scalenes in chest pain, upper back pain, jaw pain, face pain, headache, arm pain and hand pain.]

Spreading pain

Just like the pain of a heart attack spreads from the heart into the shoulder and arm, the pain of painful scalene muscles spreads throughout the chest, upper back, and chest, the arm and hand, and the side of the head. Pain referred to the back may feel like a penetrating pain stabbing through the torso.

Spreading pain

And scalene TrPs can also have several other “interesting” (in the sense of the Chinese curse2) effects: on your voice, on swallowing, on emotions, on sensations that sweep through the entire head, the sinuses, hearing, and teeth. I have found scalene TrPs to be obviously clinically relevant to conditions as seemingly unrelated as:

a professional singer with a mysterious degradation of quality in his voice (helped by releasing scalene and other throat trigger points)
at least two patients with severe chronic sinus infections that they’d actually had surgery to try to correct (one of them virtually cured by scalene trigger point release alone, the other significantly helped)
several people with severe cases of what I call “brick back,” where the space between the shoulder blades feels so stiff and stuck that it’s like there’s a cinder block there instead of bone and muscle
cutting off blood and nerve supply to the arm, because tight scalenes can impinge the brachial artery and brachial nerve plexus in the neck

So scalene trigger points are “drama queens,” with symptoms and consequences that seem out of proportion to such small and obscure muscles. They are usually making at least some contribution to anything else that goes wrong in the whole region. Like a gang, scalene TrPs can be counted on to mess up the neighbourhood. The anterior scalene in particular is a trouble-maker, causing and complicating many other problems.

The anatomy of the Anatomical Bermuda Triangle

The scalenes fan out from the sides of the neck bones to attach to the ribs.3 The scalene group consists of three muscles: the anterior, middle, and posterior scalenes. They generally attach to the sides of the neck vertebrae at the top and to the uppermost ribs at the bottom. So the scalenes are mostly head pullers: they pull the head from side to side. And although they certainly do move the neck, they are also breathing muscles, because of the way they pull up on the ribs.

And here’s some more weirdness that makes this muscle group quite interesting: in some people the scalene muscles even reach down between the ribs and attach directly to the top of the lungs, In some people the scalene muscles even reach down between the ribs and attach directly to the top of the lungs. the only muscles that attach directly to the lungs other than the diaphragm. They pull up on the membrane that surrounds the lungs. A strange muscle group indeed! Such anatomical variability is actually fairly common throughout our bodies.4

The scalenes as a group are not hard to find, but they are intricate in their details. The scalenes fill the space between three obvious structures: your collarbone, your trapezius muscle on top of your shoulder, and the long V-shaped throat muscles (sternocleidomastoid or, if that’s too much of a mouthful, just the SCM). These three structures form the (Bermuda!) triangle in which the scalenes live.

Where is Perfect Spot No. 4 and the scalene muscle group?

Perfect Spot 4 is “somewhere in the triangle.” There is indeed one particular spot, in the belly of the middle scalene, that I believe to be the most common clinically significant trigger point — the spot most likely to feel important to the patient — but I don’t want to throw you off with that and send you on a wild goose chase trying to locate exactly that spot. Virtually any location within the triangle could prove to be a nemesis, so you should definitely explore. Things change, too: Perfect Spot 4 might be in one corner of the triangle one day, and in another corner the next. Precise self-treatment isn’t necessary — a willingness to gently experiment is.

The best way to approach this area as a therapist is from above the head, with your partner face up. Without a massage table, it works well to place his or her head in the corner of a bed. Sitting at the corner, hold your fingers flat and place the pads of your fingertips in the hollow of the triangle: above the collarbone, in front of the massive trapezius muscle along the top of the shoulder, and to the outsides of the prominent V-shaped sternocleidomastoid muscles of the throat.

Is there any danger when massaging in this seemingly vulnerable area? Some, yes. Many people are concerned about the possibility of impinging blood vessels or nerves, and that is not an unreasonable concern. Do not massage this area vigorously, and do not use tools.

However, you should never be massaging yourself so hard in the first place that you could damage anything. And if you do touch the vital carotid artery or the jugular vein, the intensity of the pulse is obvious — simply back off. It’s not an appealing place to rub. You’re no more likely to “massage” your own carotid artery than your eyeball. Smaller vessels are not a concern, and nerves are remarkably robust, and generally tolerate far more pressure than most people realize. No reasonable intensity of massage is a threat.

Are there other things in the throat you should worry about? The trachea and voice box are delicate — but they are also too central to get in the way of scalene massage, and no one would tolerate any careless pressure on these parts.

In this position, your hands will be angled inward a bit, and roughly pointing at the sternum. Now press down and perhaps a little inwards with a fairly broad pressure — finger pads, not finger tips — on the ropy muscles that fill the triangle. By using a broad pressure, you can easily stimulate some TrPs and stiff muscle without having to worry about being too accurate.

Explore in the triangle with your fingertips, using small circles to find the ropy bands of muscles, gently strumming across them. The area is a rich minefield of trigger points, any of which might be worthwhile and interesting.

How should scalene massage feel?

Massage feels better on some muscles than others.5 The scalenes are not really pleasurable to massage, in general. The throat is a vulnerable body part, so many people feel threatened by pressure here — beware of underestimating it.6 and all the more so if you aren’t confident that massage is safe, or if you don’t understand the strange sensations that are so common in this area. That vulnerability seems to translate into sensitivity, so even a gentle approach may feel a bit hot, nasty, and dodgy at first — not really the kind of trigger point you want to mess around with for fun.

Wow, sign me up! Sounds great, doesn’t it? But it’s not all bad news.

Some people enjoy scalene massage right out of the box, and others can come to appreciate it after a period of “working through” and getting used to the uglier sensations. But the best case scenario is when you are actually solving a problem: if your scalenes are in distress and causing a chronic pain problem, then it’s going to feel more like you’re finding the right place to scratch an itch that you couldn’t reach before.

Maximize your chances of a positive experience by moving slowly and respectfully, and massaging the scalenes with broader, less “poky” pressure. Such pressure is more likely to produce the best case scenario: a peculiar deep ache spreading into the head, chest, back, and/or arm. At its best, scalene massage feels challenging but “profound.” The spectacular referral patterns make the scalenes feel important, the key to the region. No muscle produces more amazed comments. As an entire limb “lights up” with referred pain from a light pressure in the neck, many people will say something like, “Holy $%!@$#$!, what the hell is that?” As an entire limb “lights up” with referred pain from a light pressure in the neck, many people will say something like, “Holy $%!@$#$!, what the hell is that?” This is generally true of all referred pain, and it’s equally true of all the Perfect Spots, but “some trigger points are more equal than others.” The scalenes may be awkward and uncomfortable to massage at first, but this Perfect Spot can be very impressive in the end.

So be prepared for anything, and take it easy.

Although you might have to “work through” a little unpleasant sensation to get to the better sensations, this doesn’t mean “no pain, no gain” — do not be brutal in this area. Patients need a little time to adjust and “accept” the stimulation in this area. Persist respectfully, and there is a fair to middling chance that the sensation will change from hot to warm, from sharper to achier. It might make the transition in five minutes, or it might take a few days of sweet-talking the area. But there is a reasonable limit to how much you should try. If the effort doesn’t start to develop a bright side after a reasonable amount of time, then this Perfect Spot isn’t so perfect, and you should let it go.

[Picture of woman playing tennis, a classic way to get tennis elbow, but not actually the most common.]

Tennis, meet elbow

Tennis is the traditional way to get a case of tennis elbow, but it’s not the only way.

A surprising relationship between the scalenes and tennis elbow

This tennis elbow connection is a good example of how odd and clinically relevant the scalenes can be to conditions they don’t seem to have anything to do with at first.

The scalene muscle group has surprising importance to a condition called “tennis elbow” or lateral epicondylitis, which commonly afflicts typists as well as racquet sports players. It is generally characterized as an inflammatory condition, but it is rarely that simple.7 It is likely that myofascial TrPs, particularly Perfect Spot No. 5 in the muscles of the forearm, play a significant role in any case of tennis elbow.

And Perfect Spot No. 4 seems, in turn, to significantly affect Perfect Spot No. 5. Travell and Simons write, “Scalene muscle trigger points are frequently the key to [treatment of] forearm extensor digitorum trigger points.” That is, trigger points on the back of the forearm.8 So an interesting benefit to treating Perfect Spot No. 4 is that it may be a key to treating Perfect Spot No. 5!

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. The phenomenon of sensitive spots on the body is undeniable … but their nature remains somewhat puzzling, and the classic image of a tightly “contracted patch” of muscle could just be wrong. On the one hand, 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. On the other hand, some of that may be wrong, and all of it could essentially just be “side effects” of a more basic problem. No one really knows.

What we do know is that people hurt. Muscle pain is clinically significant, but medically obscure. As Dr. David Simons wrote, “Muscle is an orphan organ. No medical speciality claims it.” Many patients can benefit from educating themselves.

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

Not too good to be true.

Appendix B: 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 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. 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)

2Perfect Spot No. 2 — Massage Therapy for Low Back Pain

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. 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

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

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. 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

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

Go to top.

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 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. 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, 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. 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 — 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 entire human body. It is probably an accomplice in most cases of bruxism (that’s latin for “grinding your teeth”) and temporomandibular joint syndrome (a painful condition of the jaw joint), plus other unexplained painful problems in the area. 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 effectively impossible, but massage is an option: although often shockingly sensitive, Perfect Spot No. 8 can also be quite satisfying. It’s also often complicates or contributes to 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, but experienced as low back pain. 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