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updated 5/26/10

Massage Therapy for Your Quads

Perfect Spot No. 8, another one for runners, the distal vastus lateralis of the quadriceps group

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!

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 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).

A little quadriceps anatomy

Your quadriceps “muscle” is actually a group of three large muscles and one smaller one that merge just above the knee. They are:

1. vastus lateralis on the outside of the thigh,
2. vastus medialis on the inside,
3. vastus intermedius in the center,
4. and the relatively skinny and insubstantial rectus femoris lying on top, right at the front of the thigh.

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 surprising quadriceps stretching debacle

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 only elongate 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.

It’s anatomically impossible to stretch most of the quadriceps muscle! I’m not joking. You really can’t.

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!

Where is the Perfect quadriceps Spot?

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.

Does Spot #8 have anything to do with knee problems like IT band syndrome and patellar pain?

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.4

Researchers 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.

Pounding with your fists, by the way, is also a pretty great way of working this big, meaty muscle group.

Further Reading

• In SY Quite a Stretch — Stretching research clearly shows that a stretching habit isn’t good for warmup, injury prevention, preventing or treating muscle soreness, enhancing athletic performance … or even flexibility!, I go into much more depth about the confusion around stretching.
• SY The Unstretchables — Ten major muscles you can’t stretch, no matter how hard you try
• SY Save Yourself from IT Band Syndrome! — All your treatment options for Iliotibial Band Syndrome reviewed in great detail, with clear explanations of recent scientific research supporting every key point.

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 …

Appendix C: Quick Reference Guide to the Perfect Spots

Notes

1. And it’s not alone. There are actually quite a few important muscles in the human body that are virtually impossible to stretch. I call them: The Unstretchables. Return to text.
2. Which is a reasonable way of looking at it, as there is excellent evidence that trigger points are full of waste metabolites: see Toxic Muscle Knots Return to text.
3. Devan et al. Journal of Athletic Training. 2004. For a more detailed analysis of this research, see Iliotibial band syndrome and patellofemoral pain syndrome aren’t as simple as they seem. Return to text.
4. That statement is harder to back up with a single reference, but you can read about it in detail in Save Yourself from Patellofemoral Pain Syndrome!. Return to text.

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