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The butt-back connection

A lot of so-called “back” pain is actually coming from a little lower down.

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

Perfect Spot No. 12, a common (almost universal) trigger point in the superolateral origin of the gluteus maximus muscle

2,100 words, published 2005, updated 2012
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, a former massage therapist, and the Assistant Editor of Science-Based Medicine since 2009. I am nearly done with a long-procrastinated Bachelor of Health Sciences degree. I am a middle-aged runner and ultimate player with plenty of personal experience with athletic injury and chronic pain. Readers often want to know more about me and my qualifications, because my style and subject matter is controversial. Most importantly, yes, I used to actually believe and practice almost everything that I now debunk and criticize. I live by the ocean with my wife in beautiful downtown Vancouver.

illustrations by Paul Ingraham, Gary Lyons, Lindsay McGee

“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


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.


Pain Location Problems Related Muscles
in the lower back, buttocks, hip, hamstrings low back pain, sciatica, sacroiliac joint dysfunction gluteus maximus
“Big Red Books” Reference: Volume 2, Chapter 7
see chart of all spots below

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.

Amaze your friends! It’s one thing to massage a Perfect Spot in a familiar location for pain and stiffness, like under the back of skull, but it’s an even bigger treat to reveal one where none was even suspected. Confusion about where the pain is coming from is always a symptom of this spot. When it’s active, people assume they need a back rub. “My back hurts,” they say, as they point right at the top of their buttocks. “Well, that’s not actually your back — that’s your butt,” I say. People usually don’t consciously realize that it’s the buttocks that are the problem until you actually press on the spot — but then they recognize it as the epicentre of tension in the region. What’s going on?

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Why is Perfect Spot No. 12 so 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 massive and thick extensor muscle. 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 up before you start to notice them. A feeling of fatigue, stiffness, and heaviness in the area can get well-established before it actually starts to hurt, so you can build up quite a significant TrP in the gluteus maximus without being any wiser. This may explain why hardly anyone seems to know about this spot until it is massaged.

Not only is gluteus maximus a big ol’ extensor, it’s also located in what is arguably one of the least vulnerable places in 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, producing a “sweet” ache instead of sharp or burning quality.1 This is meaningful in the context of low back pain, because low back pain scares people. The great majority of low back pain patients unnecessarily fear that their pain is related to structural problems and spinal fragility.2 But not only is the spine extremely sturdy and the bark of low back pain far worse than its bite, much of the pain is usually coming from lower down — from the nearly indestructible gluteus maximus.

The single best thing you can do for the great majority of back pain patients is to reassure them, and nothing works better than to massage Perfect Spot No. 12, because it feels like it has extremely strong relevance to the back pain … yet it’s radiating from the meaty depths of this anatomically straightforward and sturdy region of pure muscle and bone.

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The top edge of the gluteus maximus muscle slices across the top of the buttocks on a diagonal line, from the low back dimple to the bump of bone on the side of the hip (greater trochanter). That ridge of muscle is fairly easy to find, even for the beginner. Pressure may feel satisfying at any point along that ridge, but Perfect Spot No. 12 is in the upper, inner end of it.

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The top edge of the gluteus maximus muscle slices across the top of the buttocks on a diagonal line, from the low back dimple to the bump of bone on the side of the hip (greater trochanter). That ridge of muscle is fairly easy to find, even for the beginner. Pressure may feel satisfying at any point along that ridge, but Perfect Spot No. 12 is in the upper, inner end of it.

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 pressing from the side, straight towards the centre.

What does Perfect Spot No. 12 feel like?

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

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 TrPs of the back muscles (which form Perfect Spot No. 13, next in the series), are just an inch or two away from Perfect Spot No. 12, and trouble in either Spot tends to irritate the other. Mature TrPs 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 TrPs return the favour. TrPs 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 sciatica.3

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 confusion arises because many therapists place an excessive focus on the clinical importance of subtle sacroiliac joint problems, as though the slightest problem here can wreak havoc.

The sacroiliac joint” — the barely-mobile joint between the pelvis and the sacrum — is one of those joints that patients sometimes learn to refer to, because they’ve heard therapists say it (somewhat like parrots imitating things people have said around them). Unfortunately, the use of the name is rarely associated with actual comprehension, either by the therapists or their innocent patients, because sacroiliac joint pain and dysfunction is so over-rated and over-diagnosed. Certainly problems with this joint do exist: my wife suffered substantial injury to her sacroiliac joint in a car accident, and I’ve seen what it can be like. But that perspective only makes me more confident that most alleged sacroiliac joint pain is probably just the discomfort associated with Perfect Spot No. 12. The joint itself is pretty robust, and is rarely a major contributor to the most common pains in the area.

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 cases 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 TrP. She also believed that it was a sacroiliac joint problem, and this had been affirmed repeatedly by therapists, so her belief was strong. However, it turned out that pressure on Perfect Spot No. 12 was rapidly therapeutic, whereas years of “adjustments” for a non-existent sacroiliac joint problem had simply failed her. Here’s what I heard from her months later:

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 TrP, and there’s nothing to be done except work through it slowly and gently.

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 No. 12 persists in the gluteus maximus for long enough, it can really do some damage.4

In 2006, researchers in Taiwan scanned some “tight asses” with an MRI machine. Specifically, they studied people with gluteus maximus contracture.5

“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 can be an important factor in a common runner’s knee problem, iliotibial band syndrome.

Can you tell yourself if you’re 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 — even hard stretching will probably have no effect.6 Once a muscle like the gluteus maximus is contractured, TrP 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 No. 12 … but it probably won’t last very long.

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.

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. 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 …

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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 

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 (this page!)

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   

Notes

  1. This difference is a massage phenomenon I’ve speculated about in An Open and Closed Case: An explanation for a strange duality of muscle sensation observed in massage therapy. BACK TO TEXT
  2. This extremely important concept is covered in extreme detail in my low back pain tutorial. Other aspects of it are discussed here and here. BACK TO TEXT
  3. 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
  4. How scary? How much damage? Not all that scary at all when compared to many other common medical problems. Approximately as scary as garden variety arthritis … but more preventable. Probably most people over 40 are getting at least a little contractured somewhere in their body. I only say “scary” because we normally think of muscle tension as something that goes away. It’s a bit daunting to realize that it can actually become permanent. BACK TO TEXT
  5. Chen et al. MRI diagnosis of contracture of the gluteus maximus muscle. American Journal of Roentgenology. 2006. PubMed #16861506. BACK TO TEXT
  6. Most people assume that if you yank on tissue hard enough for long enough, it will get permanently longer. This assumption was tested in a comprehensive 2010 review of all the science available. The verdict? Thumbs down, down, down. “The review shows that stretch is not effective for the treatment and prevention of contractures.” See Katalinic et al. While there may be other methods that work, this pretty clearly show that contractures are tough and will not yield to simple, hard stretching. Good to know. BACK TO TEXT