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.
Your “quads” are muscles that people think they know — everyone knows where the quadriceps are, what they’re about, and how to stretch them … right? Actually, they often don’t. The most common misunderstanding concerns stretching. Did you know that it’s actually anatomically impossible to stretch most of the quadriceps?1 I’ll bet you didn’t! Read on to find out why.
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).
Your quadriceps “muscle” is actually a group of three large muscles and one smaller one that merge just above the knee. They are:
The smaller rectus femoris is the only one of the group that crosses both the hip joint and the knee. It powers both of those big joints, whereas the larger three members of the group — the three vasti — only cross the knee and therefore they can only move the knee. One of the most important implications of this (and also one of the best ways to visualize it) is that there is a problem with stretching your quadriceps.
The traditional quadriceps stretch, which people often call the “runner’s stretch,” stretches only the smaller rectus femoris part of the quadriceps, because that’s the only part of the quadriceps that crosses the hip, which represents roughly 10% of the muscle tissue in the group. Yep, that’s right: probably the most familiar and popular of all stretches is simply missing 90% of the quadriceps muscle mass!
The big underlying trio of vasti muscles is anatomically impossible to stretch strongly, because they elongate only with knee flexion, and knee flexion is strictly limited — you can only flex your knee so far, because the hamstrings are in the way. When you flex your knee, the vasti obviously do elongate — but they don’t elongate much. You will never feel anything like a strong stretch in your thigh by bending your knee … unless you add hip extension into the mix.
But when you add hip extension, you have absolutely no effect whatsoever — zip, zero, zilch — on the vasti, because they simply do not cross the hip, and cannot therefore be affected in the slightest way by hip movements. However, the rectus femoris does cross the hip, and it is already stretched out a bit if your knee is flexed. So, when you extend the hip — as you do in the classic runner’s quads stretch — now you feel a stretch, but the only thing you’re feeling is the rectus femoris.
The bigger quadriceps muscles, with 90% of the quadriceps muscle mass, remain exactly as they were before you added hip extension: they stay modestly elongated by knee flexion, prevented by stretching any further by the collision of your calf with your hamstrings. There is no getting around this! There is no “better” quadriceps stretch that can somehow elongate those vasti muscles. It’s just simple biomechanics — there is simply no such thing as a strong quadriceps stretch.
This quirk of anatomy (which hardly anyone knows about) is just one more reason why I think generic stretching is generally over-rated as a form of exercise. There are too many misconceptions of this type out there!
Due to its size, the quadriceps group seems to be able to take a licking and keep on ticking. Even when significantly “polluted” by trigger points,2 the quadriceps muscles often still feel mostly fine and functional, and perform as well as needed by the average person, or even by most athletes. This is only true relative to other muscles. Don’t get me wrong — the quadriceps can still be laid low. But seemingly less easily than smaller muscles.Even when they are polluted by trigger points, the quadriceps muscle often still feel mostly fine and functional.
Even when they keep on ticking, a surprising amount of sensitivity to pressure can be lurking in those thick tissues, particularly in the big vastus lateralis muscle. There is a common trigger point there. One of the things that makes Spot No. 8 “perfect” is the tendency it has to be strongly “latent” — that is, to hide in your tissue, unbeknownst to you, until you press on it.
Perfect Spot No. 8 is somewhere in the bottom half of the vastus lateralis muscle, a few inches from the knee. It’s not on the side of the thigh and not on the top, but between the two — facing forward and out.
In that location, the vastus lateralis can be pressed against the bone underneath. While pressure at virtually any location in the vastus lateralis is likely to feel potent, Perfect Spot No. 8 is a sure thing: with anything more than mild pressure, it is virtually guaranteed to generate that classic “sweet ache” that makes us seek out massage.
Since it isn’t actually possible to stimulate most of the quadriceps muscle group with any kind of stretch, massage is a bit more important.
The clinical connections between quadriceps trigger points and the “big two” runner’s knee injures — iliotibial band syndrome (ITBS) and patellofemoral pain syndrome (PFPS) — are probably limited. Those conditions are primarily caused by tissue fatigue at the location of pain. When the tissues are irritated, everything bothers them. When they aren’t inflamed, they can put up with practically anything.
In short, biomechanical factors like grumpy and dysfunctional quadriceps muscles are undoubtedly a factor in these conditions, but they are almost certainly not a major factor.
However, that’s not the conventional wisdom.
The conventional wisdom is pretty sure of itself, and it will tell you that trigger points in the quadriceps matter a lot when it comes to your knee problems. It will tell you that your vastus lateralis is too tight and pulling your kneecap out of whack. And it will tell you that your ITB is too “tight” and needs to be “loosened,” and somehow quadriceps massage is going to do that — which is particularly odd, because the quadriceps have no mechanical connection whatsoever to the IT band, so how, exactly, does quadriceps massage loosen the IT band? Hmmm.
Congratulations if you detect a note of exasperation in my “voice” — you’re very perceptive! All of this conventional wisdom pretty much ignores the last decade of scientific research. No, double that — it ignores at least 20 years of science.
There is a lot of “recent” (up to 20 years old) evidence that all of this conventional wisdom is either wrong or at the least debatable and oversimplified. For instance, researchers have found that people with ITBS don’t have tighter IT bands than anyone else,3 and that therapists and doctors can’t reliably diagnose the existence of a so-called “patellar tracking syndrome,” let alone reliably treat it by any method.4Researchers have found that people with ITBS don’t have tighter IT bands than anyone else.
So, I really wouldn’t make too much of the clinical importance of trigger points when it comes to knee problems. Massage this Perfect Spot (and the rest of your quadriceps) for other reasons — because it feels good, because it relieves a feeling of tension and fatigue in the region, and because you can impress your friends with your innovative use of an otherwise neglected kitchen utensil. And, hey, the conventional wisdom might not be completely wrong.
Gentle pounding with your fists — the classic Swedish massage technique of tapotement — is also a pretty great way of working this big, meaty muscle group.
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 …
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)|
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|
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|
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)|
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|
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|
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|
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|
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|
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|
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|
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||related to: low back pain, sciatica, sacroiliac joint dysfunction||muscle(s): erector spinae muscle group at L5|