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A pain in the butt

And hip. And hamstrings. Gluteus medius and minimus are a common but often unsuspected cause of pain.

updated 5/26/10

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

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.

illustrations by Paul Ingraham, Lindsay McGee

One trigger point therapy treatment completely relieved a nasty stubborn hip pain that I'd had for five months!

Jan Campbell, retired French language teacher, Palm Springs, recovered easily from several months of hip pain

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!

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.

The leg pain that they produce can be so nasty that doctors, physiotherapists and other health professionals routinely mistake it for sciatica,1 a compression of the large sciatic nerve that passes through the buttocks and into the leg. Don’t be fooled. Sciatica is rarely the correct diagnosis for pain in this region.

What does Perfect Spot No. 6 feel like?

Even without nasty symptoms, pressure on these muscles can still feel important, as they usual harbour TrPs that aren’t obvious until they are poked (known as “latent” trigger points), but which are routinely responsible for stiffness, “heavy”-ness, vague discomfort, and aching throughout the the hip and buttocks and descending into the leg. Their importance is often unsuspected because the key gluteus medius and minimus TrPs actually live way out on the side of the hip, but the discomfort they produce spreads inwards and downwards — known as “referred pain,” this is the same phenomenon as the pain of a heart attack spreading into the shoulder and arm. In particular, it’s common for this referred pain to be strongest right under the butt cheek, which is why it is so often mistaken for sciatica.

Given their stealthy nature, massaging these muscles can really feel like a surprising and satisfying discovery of the true source of stiffness you did (or didn’t) know that you had — perfect characteristics for a Perfect Spot!

Anatomy and function of the gluteal muscles

The gluteus medius and minimus are the smaller cousins of the more famous gluteus maximus, the big muscle that gives shape to the buttocks (and the home of very nearby Perfect Spot No. 12). Medius and minimus are very much a pair, so much so that you can basically think of them as one muscle, and I’m going to stop including “and minimus” every time I mention them. It’s almost one muscle in two parts: they have an nearly identical shape, location, and function, both acting as lateral stabilizers, preventing the hips from swinging too far from side to side as you walk and balance. You can activate them easily just by standing on one leg and lifting the other out to the side several times; when you start to feel a burn on the sides of your hips, you are feeling your gluteus medius and minimus.

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The gluteus minimus and medius muscles are shaped like slices of pizza. (The minimus is hidden here: it is the same shape as the medius, but smaller and lying directly under it.) Perfect Spot No. 6 is usually found half way down the lateral edge, right on the side of the hip, in the “soft” area between the ridge of the pelvis, and the big bone on the side of the hip (greater trochanter). But rather than being “soft,” the edge of the gluteus medius is usually quite rigid — almost as hard as the bones above and below!

These muscles really have evolved for all-terrain activity. A life lived mostly on the flat and stable surfaces of the city offers little challenge to them, and so they are almost always weak and easily exhausted by weekend skiing trips, a walk on the beach, or basically anything that requires more balancing than usual — and so they almost always contain trigger points.2

Both the medius and minimus are shaped like a slice of pizza; the points converge downwards on the bony projection on the side of your hip, the greater trochanter at the top of the femur. Their “crust” follows the iliac crest, a bony ridge at the top of the pelvis that defines the waist. The medius completely covers the minimus, and the maximus covers most of the medius — but you can still easily reach these muscles simply by pressing into the soft tissue just below the waist at the side and back.

Where exactly is this trigger point?

Like many of the spots, Perfect Spot No. 6 is not so much a single common trigger point as a small area where you are likely to find a significant trigger point — or several of them. This area is just slightly behind the side of the hip. Or, to use the pizza as a guide, it is along the outer edge of the slice-like shape of the muscles.

The area near the tip of the pizza slice is the best place to look for TrPs, just above the greater trochanter, but explore all over the side of the hip, right where the seam of your pants would be.

Self-massage tools that are particularly useful in this location

Trigger points in this area are easy enough to find, but not particularly easy to massage on your own body. It is a spot that cries out for a massage tool, more so than many other areas: something to trap between your hip and the floor. Tennis ball massage is always a great option for this, of course — and most people already have one around — but there are some other excellent choices as well.

The KONG® dog toy is an amazingly good self-massage tool!

For instance, a KONG® dog toy is a surprisingly useful (and quirky) self-treatment tool; its unusual wedge shape allows you to roll the side of your hip onto it, the pressure increasing as you roll further. This is a difficult (and slightly absurd) process to describe, so all I can do is encourage you to take my word for it and experiment — your dog may get jealous, though.

Balls and other “pointy” tools are often too intense for the sensitive trigger points in the gluteus medius and minimus muscles. Tubes and rollers fit more naturally into the space between the bones on the side of the hip: you can settle your weight onto them and roll back and forth quite comfortably. There are countless foam rollers available to choose from — but don’t spend too much, because there are plenty of cheaper ones (and note that pool noodles also work, and may be even cheaper)! With a foam roller, it’s easy and more comfortable to just settle your weight onto the roller.

Foam rollers work well on the side of the hip.

For a firmer roller, I particularly like the spinal rollers handmade by Allan Saltzman, creator of YogaTools.com — Relieve Tension, Stiffness, and Physical Distortions with Yoga Tools. His spinal rollers are just extremely hard tubes padded with a dense, rubbery foam: simple but very handy, and much sturdier than foam rollers.

Spinal rollers by Allan Saltzman

Allan Saltzman’s simple but sturdy “spinal rollers,” built for the spine but recommended here for the side of the hip. Available at YogaTools.com.

Last but not least, for the best in a pokier self-massage, I recommend The Knobble, a massage tool classic from Pressure Positive.

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The Knobble

The Knobble is the best possible tool for applying a focussed pressure to a specific spot on the side of the hip. This is the best tool for the long term, once you know where to aim it, and have worked your way up to tolerating stronger pressures.

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 …

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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

Notes

1. Bewyer et al. “Rationale for treatment of hip abductor pain syndrome.” Iowa Orthop J. 2003. Full Abstract:
   

   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.

   Return to text.
2. At least I think that’s why they tend to contain trigger points. It’s a reasonable theory, but just an educated guess. Many common TrPs have no apparent good explanation. It’s important to bear in mind that it’s often just impossible to know exactly why individual TrPs come and go. Return to text.

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