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A pain in the butt

And hip. And hamstrings. The deep glutes are a common unsuspected source of pain.

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

1,100 words, updated 2012
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

illustrations by Paul Ingraham, Lindsay McGee

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 (jump to list below) 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 trigger points treatment guide.


Pain Location Problems Related Muscles
in the low back, hip, buttocks (especially immediately under the buttocks), side of the thigh, hamstrings sciatica, trochanteric bursitis, low back pain gluteus medius and minimus
“Big Red Books” Reference: Volume 2, Chapters 8 & 9
see chart of all spots below

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 might be radiating 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 health professionals 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 often an incorrect diagnosis for pain in this area.

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

Jan Campbell

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 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!

The deltoid of the butt: anatomy and function of the lateral gluteal muscles

The gluteus medius and minimus together are “the deltoid of the butt.” Just as the deltoid muscle lifts the arm out to the side, these lateral glutes lift the leg. They are small 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 — almost one muscle in two parts — so I’m going to stop saying “medius and minimus” every time. They have a 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 lateral glutes.

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The deltoid of the butt

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 halfway down the lateral edge, right on the side of the hip, in the meaty 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!

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The deltoid of the butt

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 halfway down the lateral edge, right on the side of the hip, in the meaty 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 a city offers little challenge to them, so they are weak and easily exhausted by weekend skiing trips, a walk on the soft sand of a beach, or really anything that requires more balancing than usual. The combination of chronic mild weakness with erratic stressful challenges may be the reason they tend to get polluted with TrPs. (But that’s just an educated guess. It’s generally impossible to know exactly why individual TrPs come and go.)

Both the medius and minimus are shaped just like a wide 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 perfect trigger point?

As with most of the spots, Perfect Spot No. 6 is not so much a single specific trigger point as a small area where you are likely to find a significant trigger point — if not several of them. This area is on the side of the hip behind it. Or, to use the pizza as a guide, it is roughly the forward half of the slice, and especially in the half near the tip of the slice. Start at the greater trochanter and explore up and back from there: 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!

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

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

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 cozily. There are countless foam rollers available — but don’t spend too much, because there are plenty of cheaper and even free improvised options (e.g. pool noodles!). With a foam roller, it’s easier to just settle your weight onto the roller.

Foam rollers work well on the side of the hip.

Foam rollers work well on the side of the hip.

For a super firm 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 very sturdy.

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.

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.

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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.

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Notes

  1. Bewyer et al. Rationale for treatment of hip abductor pain syndrome. Iowa Orthop J. 2003. PubMed #14575251.

    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.

    BACK TO TEXT

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. Their nature remains somewhat puzzling, and the classic image of a tightly “contracted patch” of muscle tissue may well be wrong. What we do know is that people hurt, and it can often be helped.

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 …

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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.

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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 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   

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

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)   

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 (this page!)

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 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    related to: low back pain, sciatica, sacroiliac joint dysfunction    muscle(s): erector spinae muscle group at L5   

14Perfect Spot No. 14 — Massage Therapy for Shoulder Pain

I avoided adding Spot 14 to this series for many years, because it’s a little tricky to find. But precision is not required: although there is one specific spot that’s especially good, nearly anywhere just under the ridge of bone on the shoulder blade is worthwhile, and often a surprising key to pain and stiffness everywhere else in the shoulder… but especially all the way around on the other side, facing forward. Read more 

for pain: any part of the shoulder, and upper arm    related to: frozen shoulder, supraspinatus tendinitis    muscle(s): infraspinatus, teres minor