published 7/21/05, updated 10/07/07

Massage Therapy for Low Back Pain (So Low That It’s Not In the Back)

Perfect Spot No. 12, in the superolateral origin of the gluteus maximus muscle

by Paul Ingraham, Vancouver, Canada MORE

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.

I have fibromyalgia and ache all the time, especially in the back and the hips. But what appears to sometimes be a backache is actually originating in the hips ... this is probably the best information I have read explaining what is really going on!
anonymous reader

I have to thank you from the bottom of my back! I have been suffering from severe, chronic low back pain and physiotherapy was no help. Out of frustration and pain I started doing my own research, and after a while I stumbled upon your explanation of the ‘Perfect Spot 12’. I located the ‘knot’ at the spot indicated, my wife followed the massage instructions, and after one somewhat painful massage I have no more pain and full freedom of motion. This is just short of a miracle from my perspective. I can now start living again and enjoying life. Thank you, thank you, and thank you again!
Pete Hamel

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!

At the top of the gluteal muscles lies a Perfect Spot among Perfect Spots: a stealthy, trouble-making brute of a trigger point that commonly forms in the roots of the gluteus maximus muscle, just below the pit of the low back. This is the kind of spot that the Perfect Spots concept is all about! Not only does it tend to produce a profound and sweet ache when stimulated, it is almost always a surprise.

Amaze your friends! It’s one thing to massage a perfect spot in a familiar location for pain and stiffness, and quite another to reveal one where none was even suspected. People usually don’t know it’s there until you press on it — yet they immediately recognize it as the epicentre of tension in the region. What’s going on?

Why is Perfect Spot No. 12 perfect for treating low back pain?

Like all the Perfect Spots, Spot No. 12 is in an extensor muscle: but gluteus maximus is a particularly large and thick extensor. Along with the quadriceps, it’s known as an “anti-gravity” muscle for its powerful lifting action. Your gluteus maximus is heavily recruited for stair climbing and jumping. Trigger points in large muscles like this are often sneaky: that is, big muscles seem to tolerate a lot of knotting before you notice. You can build up quite a significant trigger point in the gluteus maximus without being any wiser. This may explain why hardly anyone has ever noticed this spot before.

Not only is gluteus maximus a big ol’ extensor, it’s also located on what is arguably the least vulnerable place on the human body. The buttocks are well-padded, sometimes with both fat and muscle, and cover the largest bony structures in our skeleton. Muscle knots in muscles that open the body tend to feel satisfying and safe because massaging them doesn’t interfere with our defense system (closing the body), and because they are usually located on the most external surfaces (on our “shell”). So this is especially true of the sturdy and almost indestructible gluteus maximus.

How do you find Perfect Spot No. 12?

The gluteus maximus is a large muscle, and contains a few pretty good spots for massage. The best by far, however, is near the top, along the thickened edge (superolateral) where the gluteus maximus attaches to the pelvic bone. This is easy to find: just look for the low back dimples! Almost everyone has them.

If you are working on someone without low back dimples (and there are a few), you’ll have to go by feel. The dimples mark the location of a pair of distinct bumps of bone on either side of the extreme low back, approximately an inch or two away from the spine. (The skin usually dimples over them because it is sort of attached at those points.)

Once you’ve found the dimples and/or the bumps of bone, you’re practically there. The gluteus maximus is attached to the bottom edge of that bump. If you strum your fingers back and forth (side to side) just beneath the bump, you will easily feel a thick bundle of almost vertical muscle. That’s the edge of the gluteus maximus! The best place to press on it is usually about a centimetre below the bone. The best angle is usually from the side, straight towards the centre.

What does Perfect Spot No. 12 feel like?

Perfect Spot No. 12 often feels like back pain. Which is odd, because it’s in your butt.

People routinely point to this spot when I ask them to point to the center of their low back pain. “My back hurts,” they say. “Point to the spot,” I say, and they point right at the top of their buttocks. “Well, that’s not actually your back, those are your gluteals,” I say, and they reply, “Really? Feels like my back.”

Bizarrely, at least half of low back pain is actually primarily buttock pain. I call this the “butt-back connection.” The top of the pelvic bone, the iliac crest that defines the bottom of the waist, sharply divides the back from the buttocks. There are no muscles that cross that line of bone. Yet the gluteus maximus is in many ways a continuation of the back muscles, and vice versa — they work together, and they tend to suffer together.

The most significant trigger points of the back muscles (another Perfect Spot, coming later in the series), are just an inch or two away from Perfect Spot No. 12, and each one tends to irritate the other. Mature trigger points at Perfect Spot No. 12 tend to radiate a deep, back-aching sensation both downwards through the buttocks and upwards into the low back. The low back trigger points return the favour. Trigger points in the gluteus medius and minimus (see Massage Therapy for Back Pain, Hip Pain and Sciatica) can also participate in this unholy alliance — although they tend to produce more leg pain than back pain, their symptoms are often mistakenly believed to be a symptom of nerve root compression in the back, or sciatica1

It’s common for an amateur back massager to miss this crucial spot. Visually, it appears to be too low to have anything to do with the back. The inexperienced therapist will rub only in the low back itself, typically finding plenty of stiff and sore muscles, yet somehow failing to fully satisfy the patient and feeling like they are working somewhat above the real problem. Even if directed to move lower — which doesn’t always happen, because the massage recipient is often equally unsure of where the discomfort is really centered — the therapist may still not get to the source of the trouble, because Perfect Spot No. 12 is lurking right around a projection of bone and does not seem a likely place for important work. Yet that is often exactly what’s needed.

Confusion with the sacroiliac joint

When Perfect Spot No. 12 isn’t being mistaken for back pain, or contributing to false sciatica, it’s getting mistaken for sacroiliac joint pain … resulting in a nearly perfect record of being mistaken for anything other than what it is.

The sacroiliac joint is one of those joints that patients sometimes learn to repeat, because they’ve heard therapists say it — somewhat like parrots imitating things people have said around them! Unfortunately, the use of the name is not generally accompanied by understanding, either by the therapists or their innocent patients, because sacroiliac joint pain and dysfunction is over-diagnosed. The great majority of alleged sacroiliac joint pain is probably just the discomfort associated with Perfect Spot No. 12.

Perfect Spot No. 12 has a nearly perfect record of being mistaken for anything other than what it is!

Consider this typical case study, one many similar ones that I’ve seen: one of my patients spent a few years with chronic moderate intensity pain in her hip and/or low back. She was never quite sure which, true to the nature of a gluteus maximus trigger point. She also believed that it was a sacroiliac joint problem, and this had been affirmed by therapists. Her belief was strong. However, it turned out that pressure on Perfect Spot No. 12 was therapeutic, whereas years of “adjustments” for a non-existent sacroiliac joint problem had simply failed.

Just wanted to give you a quick update … my back has been absolutely fine. Unbelievable … or perhaps not, considering what I’ve learned from you! A big thank you for all your help.
Lois McConnell, retired airline executive, suffered chronic low back and hip pain for a few years

How do you treat Perfect Spot No. 12?

Although the quality of sensation in Perfect Spot No. 12 is usually among the deepest, most aching, and most relieving of all trigger point sensations in the body, about 25% of the time it can be sharper and hotter and not so pleasant. This is particularly true when the pressure is applied closer to the dimple/bump. This less satisfying feeling usually indicates either that the pressure is too much on the tendon, and you can move a little further down into the muscle proper (probably only a few millimetres) to get to the “good pain” — or it indicates a particularly tetchy trigger point, and there’s nothing to be done except work through it slowly and gently.

Perfect Spot No. 12 is usually among the deepest, most aching, and most relieving of all trigger point sensations in the body.

The pressure tolerance of this spot varies widely from person to person — true of every trigger point, but once again Perfect Spot No. 12 is an especially good example. For those who have suffered low back pain or work in a chair, this spot may be extremely sensitive and require only gentle pressure with the tip of a finger. Others may easily tolerate your entire body weight delivered through the point of your elbow. Start gently and slowly work your way up to the desired pressure.

Contracture in the gluteus maximus

Finally, on a scary note, when Perfect Spot 12 persists in the gluteus maximus for long enough, it can really do some damage.

In 2006, researchers in Taiwan scanned some “tight asses” with an MRI machine. Specifically, they studied people with gluteus maximus contracture.2 For more about the Taiwanese study, see Tight Asses Studied With MRI.

“Contracture” is a kind of über tightness in which muscle that has been tight for too long essentially freezes in place, just like your mother warned would happen to your face if you kept making ugly faces.

The MRIs showed that contracture causes your gluteus maximus to form a tough, fibrous, ropy band of muscle, while the rest of the muscle atrophies. Also, the tightness of the muscle pulls the IT band backwards, which be an important factor in a common runner’s knee problem, iliotibial band syndrome.

Can you tell yourself if your contractured? It’s difficult to confirm the presence of contracture by touch alone, but the more obvious the ropy texture, the more likely it is to be contractured.

Dealing with contracture is a tricky business, perhaps almost impossible. Once a muscle like the gluteus maximus is contractured, trigger point release becomes much more difficult. If you already have a very hard, ropy band of muscle in your gluteus maximus, you may get some relief from stimulating Perfect Spot 12 … but it probably won’t last very long.

Notes

Bewyer et al. Iowa Orthop J. 2003. Return to text.
Chen et al. American Journal of Roentgenology. 2006. Return to text.

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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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.”