massage therapy for bruxism, tmj syndrome

5/16/13 1:09 PMMassage Therapy for Bruxism, TMJ Syndrome

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Massage Therapy for Bruxism, Jaw Clenching, and TMJSyndrome

Perfect Spot No. 7, the massetermuscle of the jaw

Trigger points (TrPs), or muscleknots, are a common cause ofstubborn and strange aches andpains, and yet they are under-

diagnosed. The 13 Perfect Spots are triggerpoints that are common and yet fairly easy tomassage yourself — the most satisfying anduseful places to apply pressure to muscle. Fortough cases, see the advancedtreatment guide.

Your masseter muscle is your primary chewing muscle — not the only one,1 but themain one — and it covers the sides of the jaw just behind the cheeks. It’s also the mainmuscle that clenches your jaw and grinds your teeth, unfortunately, and it’s one of themost common locations for trigger points in the entire human body.2 It is probably anaccomplice in most cases of bruxism (that’s latin for “grinding your teeth”) and tem-poromandibular joint syndrome (a painful condition of the jaw joint), plus other unex-plained painful problems in the area.3

The masseter muscle is strong (and special)

Not only does the masseter muscle probably harbour the most common trigger pointsin the human body, the masseter is also the strongest muscle in the human body(pound for pound), although many variables make this is difficult to be sure of.4 To-gether with the temporalis muscle and a few other smaller muscles, most people cangenerate at least 150 pounds of force (lbf) between their teeth. For contrast and amuse-ment, the world record for human bite strength is 975 lbf. 975!5 More than six times

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normal. A human shark!

Muscles might all seem similar, but it’s amazing how specialized they can be. Themasseter gets extraordinary strength from a “multipennate” arrangement of fibresthat’s like a complex feather — fibres converging diagonally on several internal ten-dons.6 This feathered arrangement favours torque over speed, making the masseter avery “low gear” muscle, slow but powerful and efficient, lots of chewing bang foryour masseter buck. The physics details are a bit mind-bendy.7

Why is the masseter muscle a Perfect Spot for massage?

It’s easy enough to imagine why this muscle might enjoy the occasional massage.Whose jaw isn’t a bit tense? But the masseter’s potential to wreak havoc — and itsneed for therapy — is often underestimated by the public and health care profession-als alike (although I’m pleased to see a surprisingly strong interest in the subjectamongst dental specialists). When irritated, masseter muscle knots can cause and/oraggravate several problems:

Headaches, of course — this makes strong intuitive sense to most people. There seemsto be a pretty strong connection between tension headaches and jaw clenching. This ispartly due to the temporalis muscle, which is reflexively massaged by everyone witha headache. But the masseter is often neglected, even though it is by far the more pow-erful jaw muscle. They really both need some attention — massaging above and be-low the cheekbone. I actually considered defining Spot No. 7 as the temple and themasseter.8

Earaches and toothaches — which are much less obvious. A masseter trigger pointcan radiate pain directly into a tooth. Travell and Simons quip, “This can lead to disas-trous results for an innocent tooth.”9 I once suffered a dramatic case of a “toothache”that was completely relieved by a massage therapist the day before an emergency ap-pointment with the dentist: a particularly vivid experience, which originally got meinterested in trigger points.

Tinnitus (ringing in the ears) and dizziness. Both can be serious and complex prob-lems, and are definitely not necessarily caused by masseter trigger points. There aremany other potential contributing factors and causes of these conditions — but themasseter is one of the possible causes that should be considered.10



Bruxism, or grinding and cracking of molars.

Temporomandibular joint syndrome, which is a slow, painful failure of jaw joint func-tion.

As you can see, masseter problems are not to be taken lightly.

How do you massage the masseter muscle?

Fortunately, it’s easy — really easy — to massage and soothe your own masseter mus-cle, which is what makes it such a particularly perfect Perfect Spot. It has both greatneeds and it’s unusually easy and satisfying to self-massage.

The masseter muscle “hangs” from the underside of the cheekbone on the side of theface. The bottom of the muscle attaches to a broad area on the side of the jawbone.

Perfect Spot No. 7 is conveniently located in a notch in the cheekbone, about one inchin front of your ears. The notch is on the underside of the cheekbone, it’s easy to find,and your thumb or fingertip will fit into it nicely, unless you have freakishly largehands. If you press firmly inward and upwards with your thumb in the cheekbonenotch, you will usually be rewarded with a sweet ache.

The rest of the masseter muscle, however, tends to feel like not much, or unpleasantlytender. Although the entire muscle can be rubbed gently, most people will find thatthe Perfect Spot is definitely limited to the upper edge of the muscle.

Spot 7 is a sturdy piece of anatomy, so don’t be afraid to work steadily up to hardpressure — if that’s what you feel like you want. Either constant pressure or small,kneading circles are both appropriate. Since this spot is so tough, another good trick isto use a knuckle for extra pressure. A useful tool in this location is Pressure Positive’sKnobble productshow — it’s easy to lie down on your side and let the weight of yourhead apply a steady, firm pressure, with the tip fitting nicely into the cheekbonenotch.

Two tricks for learning to relax your jaw

Does anyone go to the dentist anymore and not get a prescription for a mouth guard? Judging by the inevitable prescriptions, apparently everyone has some kind of jaw-

clenching problem. I do not know if this is actually the case, and sometimes I feel sus-

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Simply willing yourself to stop clenching seems to bealmost completely ineffective

picious that the problem is greatly over-diagnosed (because selling mouth appliancesis probably profitable). Then again, many people (including my wife) have actualcracks in their molars from clenching so hard — and it’s kind of hard to argue thatthere isn’t a problem there!

This article is mostly about massaging Perfect Spot 7 in the masseter, but it’s obviouslypotentially extremely helpful for temporomandibular joint syndrome, bruxism,clenching, and grinding if you can also figure out how to relax your jaw. But this is noteasy. A nice massage (or any other relaxing experience) is a helpful start, but itdoesn’t do much for long.11 And simply willing yourself to stop clenching seems al-most completely ineffective. I’ve known manypeople who have tried to get serious about re-minding themselves to stop clenching, using egg timers and so on … with rather un-derwhelming results.

So what can you do? How can you possibly learn to clench less? Here are two ideasthat I think work better than simply “trying hard” not to clench:

Slur your speech as though you are so sleepy that you can hardly form words. Youknow that lovely feeling when you’re waking up slowly, in no hurry, and you’re con-scious yet not even remotely ready to move or speak yet? That floaty, delicious feelingof happy paralysis? Of complete contentment to just lie there? Don’t just visualize thatfeeling, actually act like you feel that way, in your mouth. Try to say, softly but out loud,“I’m so relaxed I can hardly talk.” But slur your words. Literally slur them. Slur themlike your mouth is so relaxed you are having trouble making words! You will findthat this is quick and effortless way to relax your jaw. It won’t necessarily last, but it isa most helpful way to quickly get back to the state you want.

I use this technique even when there are people around. I find that I can easily justmouth the words “I can hardly talk,” making no noise, and immediately access thesensory experience of jaw relaxation, with no one around me having a clue aboutwhat I’m to.

Spend long periods of time with your jaw wide open. Hold your mouth open at leastwide enough to fit a finger between your teeth for one full hour. Not just open, butopen wide — the exaggerated reversal from clenched to wide open helps to break thehabit of clenching much more quickly. Every time during the hour that you catchyourself with your teeth together, simply calmly stretch your mouth open again. After



Excellent.

Now, don’t move.

an hour of this, clenching starts to feel abnormal,and you will find it much easier to keep yourjaw relaxed for some time afterwards.

You may also find it helpful to actually propyour mouth open with something durable andspit-proof. Most people will salivate too muchto keep this up for an entire long session, but itcan be a useful way to help you focus on thechallenge for a few minutes at a time. Some peo-ple may find it practical for longer.

This intensive approach is generally a muchmore effective method of breaking the clenchinghabit than scattered self-reminders to “stopclenching,” which just never really take. If you are really determined, spend an hour aday doing this — if you put in the time, you really can’t fail. I estimate that most peo-ple need 5–10 hours of practice in a week to put a good dent in a clenching habit. Ofcourse, life is likely to regenerate the problem back sooner or later … but you willknow what to do when that happens.

Good luck!

Notes

1. The other major one is the temporalis muscle, which covers more of the side ofthe head than most people realize: the entire temple, of course, but quite a bitmore above and behind that. BACK TO TEXT

2. Travell et al. Myofascial Pain and Dysfunction. 1999. amazon.com p330. Severalstudies are discussed that conclude that myofascial trigger points in the superfi-cial masseter muscle are either the most common, or the second most common,of all the trigger points studied. It’s a hard thing to nail down for sure, but itseems pretty clear that it’s an extremely prominent “Perfect Spot!” BACK TOTEXT

3. That’s actually an exaggeration, but it’s a fair one. In fact, there are almost cer-tainly people who have those problems and no masseter trigger points — but thevast majority would still have some kind of dysfunction of the masseter and oth-er jaw muscles. For instance, with or without trigger points on a given day, the

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masseter would probably still be “tight” (high toned) in these patients. BACK TOTEXT

4. The tongue is also popularly claimed to be the most powerful muscle, but that’sreally hard to substantiate. The tongue isn’t one muscle, but a muscle group, andit can’t apply force in a way that can be compared meaningfully to other mus-cles. How, exactly, do you test tongue strength? Tongue push-ups? BACK TOTEXT

5. According to the 1992 Guinness Book of Records, in 1986 Richard Hofmann of LakeCity, Florida achieved a bite strength of 975 lbs. for two seconds. BACK TOTEXT

6. “Pennate” just means “like a feather,” with diagonal fibres converging on a line— a tendon. In a “multi” pennate muscle, there are multiple and dividing centraltendons. The result is a very complex, densely packed feathering of fibres. Thereare only a few multipennate muscles in the body, like the deltoid on the shoul-der, and most of the small muscles in the hands and feet. But the masseter is theking of “pennatedness.” BACK TO TEXT

7. Pennate muscle power is a winch: powerful but slow, and you need more cableto pull shorter distances. Pennate muscles exploit the pulley effect by pulling onthe sides of tendons that run all the way through the muscle, converging onthem at angles. Imagine a tug-of-war team with ropes tied to the main rope —you could have at least twice as many pullers! More fibres pulling on a tendonmeans that pennate muscles are found in the “tight spaces” in the body wherepower is needed without a lot of mass. In contrast, muscles with parallel fibres,like the biceps, pull directly on their target bone, and so they can pull faster andfarther, but they are also weaker pound-for-pound and take up a lot of room. Ifyou converted pennated muscles to a parallel fibre structure, they would have tobe roughly twice as big! Imagine doubling the size of your masseters. Chipmunk!BACK TO TEXT

8. I decided against it because the two halves of the spot are so different in charac-ter. The temporalis is much thinner, massage there needs to be generally moredelicate and superficial, and it feels more like massage of the surface of the headthan the jaw. Only about a centimetre away, just on the other side of the cheek-bone, the top of the masseter is sturdy and thick, and tolerates strong pressurewhich feels more much more penetrating and much more relevant to jaw ten-sion. BACK TO TEXT

9. Travell et al. Myofascial Pain and Dysfunction. 1999. amazon.com p339 BACK TO

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TEXT10. Rocha et al. Myofascial trigger points: another way of modulating tinnitus. Prog

Brain Res. 2007.

In 2007, these researchers found that “in 56% of patients with tinnitus and MTPs,the tinnitus could be modulated by applying digital compression of such points,mainly those of the masseter muscle.” And how many people with tinnitus hadtrigger points? Quite a few. The researchers found “a strong correlation betweentinnitus and the presence of MTPs in head, neck and shoulder girdle.”

BACK TO TEXT11. This is one of the classic problems with massage. Although massage does appear

to be very helpful for some people, some of the time, the results are a bit under-whelming on average — and the benefits are notoriously brief. This is discussedin much more detail in both my advanced trigger points tutorial, and also mygeneral massage review, Does Massage Therapy Work?. 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 probablyrelieve some pain cheaply and safely in many cases. Good bang for buck, and littlerisk. 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 con-troversy about the science of trigger points. The phenomenon of sensitive spots on thebody is undeniable … but their nature remains somewhat puzzling, and the classicimage 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 tissuechemistry, and now a new MRI-like technology can now show them as well. On theother hand, some of that may be wrong, and all of it could essentially just be “side ef-fects” of a more basic problem. No one really knows.

What we do know is that people hurt. Muscle pain is clinically significant, but med-ically obscure. As Dr. David Simons wrote, “Muscle is an orphan organ. No medicalspeciality claims it.” Many patients can benefit from educating themselves.

The Perfect Spots are based on a decade of my own clinical experience as a massagetherapist, and years of extensive science journalism on the topic. Want to know more?

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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 isa valuable life skill. Practically anyone can benefit at least a little, andmany 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 formassage in the human body. No other patch of muscle gets such rave reviews. It haseverything: deeply relaxing and satisfying sensations, and a dramatic therapeutic rele-vance 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 im-portant as they are. Read more.

for pain: almost anywhere in thehead, face and neck, but especiallythe side of the head, behind the ear,the temples and forehead

related to: headache, neckpain, migraine

muscle(s): suboccipitalmuscles (recti capitisposteriores major andminor, obliqui inferior andsuperior)

2Perfect Spot No. 2 — Massage Therapy for Low Back Pain

This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest riband your spine — right where the stability of the rib cage gives way to the relative in-stability of the lumbar spine. Muscle tends to bunch up around this joint between thelast of the thoracic vertebrae and the first of the lumbar. The sweet spot consists oftrigger points in the upper-central corner of the quadratus (square) lumborum muscleand 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): quadratuslumborum, erector spinae

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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 howvulnerable that meat can be. Even if you’ve never suffered so painfully, your shinsprobably still suffer in silence — latent trigger points in the upper third of the shinthat 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, dropfoot, anterior compartmentsyndrome, medial tibialstress syndrome

muscle(s): tibialis anterior

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

Deep within the Anatomical Bermuda Triangle, a triangular region on the side of theneck, is the cantankerous scalene muscle group. Massage therapists have vanishedwhile working in this mysterious area, never to be seen again. The region and its mus-cles are complex and peculiar, and many lesser-trained massage therapists have lowconfidence working with them. Read more.

for pain: in the upper back (especiallyinner edge of the shoulder blade),neck, side of the face, upper chest,shoulder, arm, hand

related to: thoracic outletsyndrome, lump in thethroat, hoarseness, TMJsyndrome

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 asingle thick tendon, the common extensor tendon. At the point where the musclesconverge, in the muscles that extend the wrist and fingers, lies one of the most in-evitable myofascial TrPs in modern civilization: Perfect Spot No. 5. It is constantly andgreatly aggravated both by computer usage today and by the use of a pen in simplertimes — and by the occasional tennis match, then and now. Read more.

for pain: in the elbow, arm, wrist, andhand

related to: carpal tunnelsyndrome, tennis elbow(lateral epicondylitis),golfer’s elbow (medialepicondylitis), thoracicoutlet syndrome, and

muscle(s): extensor musclesof the forearm, mobile wad(brachioradialis, extensorcarpi radialis longus andbrevis), extensor digitorum,

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several more 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 ofyour trouble may well be caused by trigger points in the obscure gluteus medius andminimus muscles, a pair of pizza-slice shaped muscles a little forward of your hippocket. Other muscles in the region are usually involved as well, such as the gluteusmaximus, piriformis, and the lumbar paraspinal muscles. However, the gluteusmedius and minimus are a bit special: their contribution to pain in this area is particu-larly significant, and yet people who have buttock and leg pain rarely suspect thatmuch 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 immediatelyunder the buttocks), side of the thigh,hamstrings

related to: sciatica,trochanteric bursitis, lowback pain

muscle(s): gluteus mediusand minimus

7THIS PAGE (Perfect Spot No. 7 — Massage Therapy for Bruxism, Jaw Clenching,and TMJ Syndrome)

8Perfect Spot No. 8 — Massage Therapy for Your Quads

A lot of quadriceps aching, stiffness and fatigue emanates from an epicentre of “knot-ted” muscle in the lower third of the thigh, in the vastus lateralis, a huge muscle — oneof your biggest — that dominates the lateral part of the leg. Stretching it is effectivelyimpossible, but massage is an option: although often shockingly sensitive, PerfectSpot No. 8 can also be quite satisfying. It’s also often complicates or contributes to oth-er problems in the area, especially runner’s knee (iliotibial band syndrome). Readmore.

for pain: in the lower half of thethigh, knee

related to: iliotibial bandsyndrome, patellofemoralpain syndrome

muscle(s): quadriceps(vastus lateralis, vastuslateralis, vastus medialis,rectus femoris)

9Perfect Spot No. 9 — Massage Therapy for Your Pectorals

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The “pecs” are popular muscles. Of the 700+ muscles in the human body, the pec-toralis major is one of the dozen or so that most people can name and point to. It alsoharbours 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 inboth quality and intensity. Read more.

for pain: anywhere in the chest,upper arm

related to: “heart attack,”respiratory dysfunction muscle(s): pectoralis major

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 thickcolumns of muscle beside the spine are routinely littered with muscle knots from topto bottom. Nevertheless, there is one section of the group where massage is particular-ly appreciated: from the thick muscle at the base of the neck, down through the regionbetween the shoulder blades, tapering off around their lower tips. There is no doubtthat 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 NotIn the Back)

At the top of the gluteal muscles lies a Perfect Spot among Perfect Spots: a sneaky buttrouble-making brute of a TrP that commonly forms in the roots of the gluteus max-imus muscle, just below the pit of the low back, but experienced as low back pain. Thisis the kind of spot that the Perfect Spots concept is really all about — not only does ittend to produce a profound and sweet ache when massaged, but the extent of thepain 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 jointdysfunction

muscle(s): gluteusmaximus

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


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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 arelief it is to be able to treat them. Perfect Spot No. 13 is perhaps the ultimate, thequintessential “right where I thought it was” trigger point: right at the very bottom ofthe thick columns of muscle, in the “pit” of the low back. Read more.

for pain: in the low back, buttocks,hamstrings


muscle(s): erector spinaemuscle group at L5

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

Trigger points (TrPs), or muscle knots, are a common cause of stubborn and strangeaches and pains, and yet they are under-diagnosed. The 13 Perfect Spots are triggerpoints that are common and yet fairly easy to massage yourself — the most satisfyingand useful places to apply pressure to muscle. For tough cases, see the advanced treat-ment guide.

Your “quads” are muscles that people think they know — everyone knows where thequadriceps are, what they’re about, and how to stretch them … right? Actually, theyoften don’t. The most common misunderstanding concerns stretching. Did you knowthat it’s actually anatomically impossible to stretch most of the quadriceps?1 I’ll bet youdidn’t! Read on to find out why.

A lot of quadriceps aching, stiffness and fatigue emanates from an epicentre of “knot-ted” muscle in the lower third of the thigh, in the vastus lateralis, a huge muscle — oneof your biggest — that dominates the lateral part of the leg. Stretching it is effectivelyimpossible, but massage is an option: although often shockingly sensitive, PerfectSpot No. 8 can also be quite satisfying. It’s also often complicates or contributes to oth-er problems in the area, especially runner’s knee (iliotibial band syndrome).





The quadriceps are a huge muscle group. The blue circle marks Perfect Spot 8.

A little quadriceps anatomy

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

1. vastus lateralis on the outside of the thigh2. vastus medialis on the inside3. the relatively skinny and insubstantial rectus femoris lying on top, right at the

front of the thigh (it is drawn a little too thick and beefy in the diagram here)4. vastus intermedius in the center (hidden underneath the rectus femoris)

The smaller rectus femoris is the only one of the group that crosses both the hip jointand the knee. It powers both of those big joints, whereas the larger three members ofthe group — the three vasti — only cross the knee and therefore they can only movethe knee. One of the most important implications of this (and also one of the bestways 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,”

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stretches only the smaller rectus femoris part of the quadriceps, because that’s the onlypart of the quadriceps that crosses the hip, which represents roughly 10% of the mus-cle tissue in the group. Yep, that’s right: probably the most familiar and popular of allstretches 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 youflex your knee, the vasti obviously do elongate — but they don’t elongate much. Youwill 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 there-fore be affected in the slightest way by hip movements. However, the rectus femorisdoes cross the hip, and it is already stretched out a bit if your knee is flexed. So, whenyou extend the hip — as you do in the classic runner’s quads stretch — now you feel astretch, but the only thing you’re feeling is the rectus femoris.

The bigger quadriceps muscles, with 90% of the quadriceps muscle mass, remain ex-actly as they were before you added hip extension: they stay modestly elongated byknee flexion, prevented by stretching any further by the collision of your calf withyour hamstrings. There is no getting around this! There is no “better” quadriceps

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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 reasonwhy I think generic stretching is generally over-rated as a form of exercise. There aretoo 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 onticking. Even when significantly “polluted” by trigger points,2 the quadriceps mus-cles often still feel mostly fine and functional, and perform as well as needed by theaverage 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 easilythan smaller muscles.

Even when they are polluted bytrigger points, the quadricepsmuscle often still feel mostly fineand functional.

Even when they keep on ticking, a surprising amount of sensitivity to pressure can belurking in those thick tissues, particularly in the big vastus lateralis muscle. There is acommon trigger point there. One of the things that makes Spot No. 8 “perfect” is thetendency it has to be strongly “latent” — that is, to hide in your tissue, unbeknownstto you, until you press on it.

Perfect Spot No. 8 is somewhere in the bottom half of the vastus lateralis muscle, afew inches from the knee. It’s not on the side of the thigh and not on the top, but be-tween the two — facing forward and out.

In that location, the vastus lateralis can be pressed against the bone underneath. Whilepressure at virtually any location in the vastus lateralis is likely to feel potent, PerfectSpot No. 8 is a sure thing: with anything more than mild pressure, it is virtually guar-anteed 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 withany kind of stretch, massage is a bit more important.



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

The clinical connections between quadriceps trigger points and the “big two” runner’sknee injures — iliotibial band syndrome (ITBS) and patellofemoral pain syndrome(PFPS) — are probably limited. Those conditions are primarily caused by tissue fatigueat the location of pain. When the tissues are irritated, everything bothers them. Whenthey aren’t inflamed, they can put up with practically anything.

In short, biomechanical factors like grumpy and dysfunctional quadriceps muscles areundoubtedly a factor in these conditions, but they are almost certainly not a major fac-tor.

However, that’s not the conventional wisdom.

The conventional wisdom is pretty sure of itself, and it will tell you that trigger pointsin the quadriceps matter a lot when it comes to your knee problems. It will tell youthat your vastus lateralis is too tight and pulling your kneecap out of whack. And itwill tell you that your ITB is too “tight” and needs to be “loosened,” and somehowquadriceps massage is going to do that — which is particularly odd, because thequadriceps have no mechanical connection whatsoever to the IT band, so how, exact-ly, does quadriceps massage loosen the IT band? Hmmm.

Congratulations if you detect a note of exasperation in my “voice” — you’re very per-ceptive! All of this conventional wisdom pretty much ignores the last decade of scien-tific 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 wis-dom is either wrong or at the least debatable and oversimplified. For instance, re-searchers have found that people with ITBS don’t have tighter IT bands than anyoneelse,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 peoplewith ITBS don’t have tighter ITbands than anyone else.

So, I really wouldn’t make too much of the clinical importance of trigger points whenit 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 andfatigue in the region, and because you can impress your friends with your innovativeuse of an otherwise neglected kitchen utensil. And, hey, the conventional wisdommight not be completely wrong.

Gentle pounding with your fists — the classic Swedish massage technique of tapote-ment — 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 habitisn’t good for much of anything that people think it is, I go into much moredepth about the confusion around stretching.SY The Unstretchables — Eleven major muscles you can’t stretch, no matter howhard you trySY Save Yourself from IT Band Syndrome! — All your treatment options for Ili-otibial Band Syndrome reviewed in great detail, with clear explanations of recentscientific research supporting every key point.





The Perfect Spots are based on a decade of my own clinical experience as a massage

http://saveyourself.ca/articles/stretching.php

http://saveyourself.ca/articles/unstretchables.php

http://saveyourself.ca/tutorials/iliotibial-band-syndrome.php







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 …


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 fromstubborn aches and pains. The first several sections are free.








This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest riband your spine — right where the stability of the rib cage gives way to the relative in-








stability of the lumbar spine. Muscle tends to bunch up around this joint between thelast of the thoracic vertebrae and the first of the lumbar. The sweet spot consists oftrigger points in the upper-central corner of the quadratus (square) lumborum muscleand in the thick column of muscle that braces the spine. Read more.















Just beyond your elbow, all the muscles on the back of your forearm converge into asingle thick tendon, the common extensor tendon. At the point where the musclesconverge, in the muscles that extend the wrist and fingers, lies one of the most in-









evitable myofascial TrPs in modern civilization: Perfect Spot No. 5. It is constantly andgreatly aggravated both by computer usage today and by the use of a pen in simplertimes — and by the occasional tennis match, then and now. Read more.


related to: carpal tunnelsyndrome, tennis elbow(lateral epicondylitis),golfer’s elbow (medialepicondylitis), thoracicoutlet syndrome, andseveral more

muscle(s): extensor musclesof the forearm, mobile wad(brachioradialis, extensorcarpi radialis longus andbrevis), extensor digitorum,extensor carpi ulnaris






7Perfect Spot No. 7 — Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syn-drome

Your masseter muscle is your primary chewing muscle — not the only one, but themain one — and it covers the sides of the jaw just behind the cheeks. It’s also the mainmuscle that clenches your jaw and grinds your teeth, unfortunately, and it’s one of themost common locations for trigger points in the entire human body. It is probably anaccomplice in most cases of bruxism (that’s latin for “grinding your teeth”) and tem-poromandibular joint syndrome (a painful condition of the jaw joint), plus other unex-plained painful problems in the area. Read more.

related to: bruxism,




http://saveyourself.ca/articles/perfect-spots/spot-07-masseter.php




for pain: in the side of the face, jaw,teeth (rarely)

headache, jaw clenching,TMJ syndrome, toothache,tinnitus

muscle(s): masseter

8THIS PAGE (Perfect Spot No. 8 — Massage Therapy for Your Quads)








muscle group















Some of the Perfect Spots are perfect because they are “surprising” — they aren’twhere 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 arelief it is to be able to treat them. Perfect Spot No. 13 is perhaps the ultimate, thequintessential “right where I thought it was” trigger point: right at the very bottom ofthe thick columns of muscle, in the “pit” of the low back. Read more.




Notes

1. And it’s not alone. There are actually quite a few important muscles in the hu-man body that are virtually impossible to stretch. I call them: The Unstretchables.BACK TO TEXT

2. Which is a reasonable way of looking at it, as there is intriguing evidence thattrigger points are full of waste metabolites: see Toxic Muscle Knots BACK TOTEXT

3. Devan et al. A Prospective Study of Overuse Knee Injuries Among Female Ath-letes With Muscle Imbalances and Structural Abnormalities. Journal of AthleticTraining. 2004. PubMed #15496997. For a more detailed analysis of this research,see Iliotibial band syndrome and patellofemoral pain syndrome aren’t as simpleas they seem. BACK TO TEXT

4. That statement is harder to back up with a single reference, but you can readabout it in detail in Save Yourself from Patellofemoral Pain Syndrome!. BACKTO TEXT



http://saveyourself.ca/articles/unstretchables.php

http://saveyourself.ca/articles/toxic-trigger-points.php

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC522150/

http://www.ncbi.nlm.nih.gov/pubmed/15496997

http://saveyourself.ca/articles/shorts/2007-05-27-itbs-pfps-not-simple.php

http://saveyourself.ca/tutorials/patellofemoral-pain-syndrome.php



Perfect Spot No. 9, in the pectoralis major muscle of the chest


The “pecs” are popular muscles. Of the 700+ muscles1 in the human body, the pec-toralis major is one of the dozen or so that most people can name and point to. It alsoharbours 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 inboth quality and intensity.

The pectoralis major covers the entire top half of your chest. It is mostly an armmover, although it also stabilizes the joint between your sternum and collar bone.Specifically, it is the hugging muscle: it powerfully pulls and rotates the arms towardsthe center of your body. Like all the big flexors, it’s incredibly strong. The pectoralismajor is so large, spreading out like a fan across the entire chest, that no matter whatposition the shoulder is in, the pectoralis major can do its job with at least some of its

http://saveyourself.ca/resources/images/spot-09-pectoralis-main-xl.jpg




fibers.

(The pectoralis minor, by the way, is quite a different muscle. As its name suggests, itis much smaller. It is completely covered by the pectoralis major, and does not movethe arm at all!)

The pectoralis major is also, interestingly, one of the only muscles in the human bodythat is almost always much larger in men than it is in women, which accounts formuch of the difference in upper body strength between the genders. I’ve massagedthousands of people, and even the strongest women usually have relatively thin pec-toralis major muscles. Regardless, Perfect Spot No. 9 is a good massage location forboth men and women.

No. 9 is easy to find by touch, because it is on the edge of a distinctive pocket or hol-low directly underneath your collarbone. The pocket is a small, umuscled space be-tween the deltoid and the pectoralis major. If you explore right below your collar-bone, it is easy to find the soft spot between these two large muscles. Once you’vefound it, press towards the sternum against the edge of the hollow — that’s pectoralismajor you’re pressing — and you’ve found Perfect Spot No. 9.

Thumb pressure is often adequate to stimulate this spot, but many people — especial-ly men, with their larger pectorals — may need knuckles or even an elbow to get aclear signal.

Pressure on Spot No. 9 tends torelieve that uncomfortable sense ofconstriction and stagnancy in thechest.

This spot feels good because the pectoralis major is partly responsible for the commonproblem of a collapsed chest, the shoulders rolled forward and inward. Almost every-one feels tight in the chest because of this, particularly people who routinely work orplay with computers (which is almost everyone, these days). Pressure on Spot No. 9tends to relieve that uncomfortable sense of constriction and stagnancy in the chest,creating a sense of having more space to breathe in, which is quite pleasant.

Although No. 9 is a specific spot on the edge of the pectoralis major, it’s also quite ef-fective to massage the entire space underneath the clavicle, using the big knuckles.



You would need some oil or lotion for this, of course, and it’s best to glide towardsthe centre, catching Spot No. 9 along the way.

Bonus pectoralis major tip

A lot of men would like to have better developed and well-defined pectoralis majormuscles for aesthetic reasons, because “huge pecs” are pretty much the definition of amasculine trait. Unfortunately, few men understand which exercises will achieve thiseffect! The confusion arises from the fact that the bottom half of the pectoralis majorperforms some different functions than the top half. To define the pectoralis major,you primarily need to exercise the bottom half of the muscle. While all pectoralis majorfibres adduct and internally rotate the shoulder, only the lower fibres extend the shoul-der. Therefore, the best pectoralis major training exercises include some resistance toshoulder extension. Those exercises are:

chin ups or front lat (latissimus dorsi) pull-downs with a wide grip2a standard bench press or a dumbbell press on a decline bench (that’s with thefeet higher than the head)barbell pullover, in which you lie on your back, holding a barbell over yourhead, and then lift it over your facecable crossover, in which you pull weighted cables from high and outside to-wards the center of your body

Note that standard wide-position push ups are a good general pectoralis major exer-cise, but do not isolate any part of the pectoralis major.

Further Reading

Descriptions of the chest exercises mentioned in the last section, and many more.



But pain is difficult and complex, no treatment is perfect, and there is legitimate con-troversy about the science of trigger points. The phenomenon of sensitive spots on thebody is undeniable … but their nature remains somewhat puzzling, and the classic

http://www.shapefit.com/training-chest.html



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 tissuechemistry, and now a new MRI-like technology can now show them as well. On theother hand, some of that may be wrong, and all of it could essentially just be “side ef-fects” of a more basic problem. No one really knows.


The Perfect Spots are based on a decade of my own clinical experience as a massagetherapist, 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 formassage in the human body. No other patch of muscle gets such rave reviews. It haseverything: deeply relaxing and satisfying sensations, and a dramatic therapeutic rele-vance 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 im-










portant as they are. Read more.





This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest riband your spine — right where the stability of the rib cage gives way to the relative in-stability of the lumbar spine. Muscle tends to bunch up around this joint between thelast of the thoracic vertebrae and the first of the lumbar. The sweet spot consists oftrigger points in the upper-central corner of the quadratus (square) lumborum muscleand in the thick column of muscle that braces the spine. Read more.










Deep within the Anatomical Bermuda Triangle, a triangular region on the side of theneck, is the cantankerous scalene muscle group. Massage therapists have vanishedwhile working in this mysterious area, never to be seen again. The region and its mus-cles are complex and peculiar, and many lesser-trained massage therapists have low









confidence working with them. Read more.














7Perfect Spot No. 7 — Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syn-









drome



related to: bruxism,headache, jaw clenching,TMJ syndrome, toothache,tinnitus

muscle(s): masseter






9THIS PAGE (Perfect Spot No. 9 — Massage Therapy for Your Pectorals)


This “spot” is too large to really be called a “spot” — it’s more of an area. The thickcolumns of muscle beside the spine are routinely littered with muscle knots from topto bottom. Nevertheless, there is one section of the group where massage is particular-ly appreciated: from the thick muscle at the base of the neck, down through the regionbetween the shoulder blades, tapering off around their lower tips. There is no doubtthat 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.


muscle group











Notes

1. See How Many Muscles? BACK TO TEXT2. Signorile et al. A comparative electromyographical investigation of muscle uti-

lization patterns using various hand positions during the lat pull-down. Journalof Strength & Conditioning Research. 2002. PubMed #12423182. BACK TO TEXT

Perfect Spot No. 10, in the arch muscles of the foot






http://saveyourself.ca/articles/biological-literacy/how-many-muscles.php

http://saveyourself.ca/bibliography.php?sig





If you have — or think you may have — plantar fasciitis, you may prefer to startwith this article instead: Save Yourself from Plantar Fasciitis!

The tenth of the Perfect Spots is one of the most popular of the lot, and right underyour feet — literally. It lies in the center of the arch muscles of the foot. This is one ofthe Perfect Spots that everyone knows about. No massage is complete without a footmassage!

Why is the arch of the foot a Perfect Spot for a massage?

It isn't difficult to understand why the arch muscles of the foot would harbour a Per-fect Spot for massage. They are, after all, the hardest working muscles in the humanbody. Our feet absorb an incredible amount of punishment, yet usually feel no worsethan just stiff and tired. Injury here is common, but not nearly as common as youmight expect.

The arch of the foot is a fascinating structure. The arch is like a bow without an arrow,and its curved shape is created by a “string” of muscles and elastic connective tissues.Every time you take a step, your weight pushes down on the arch. It doesn’t collapsebecause of an artful combination of bone shape, springy ligaments, long “stirrupt”tendons from leg muscles … and the arch muscles. The arch muscles of the foot itselfdon’t actually “kick in” until you reach quite heavy loads: about 400 pounds.1 Al-though that sounds like quite a lot, loading may spike that high in an average personwith every step. We don’t have muscles there for nothing, of course! (The biggest archsupporter is probably the tibialis posterior, deep in the calf.2 And the tibialis anterioris another one — and it also has a perfect spot for massage, no. 3). Still, the forces on


http://saveyourself.ca/tutorials/plantar-fasciitis.php




all of these structures are relentless and often very large — no wonder they get ex-hausted!

When these support mechanisms fail, the connective tissue in the arch may start to de-generate and fray — a kind of tendonits called plantar fasciitis. However, many peo-ple just develop really significant muscle knots in the arch, and in other arch support-ing muscles.

There is another reason why this spot is significant. The skin of the feet has a dispro-portionate number of nerve endings, like the face and the hands, yet the feet are gen-erally abused or at least neglected. Therefore the sensations of foot massage seem par-ticularly rich and diverse in contrast to the usual stomp, stomp, stomp of their dailystimulus.

How do you find muscle knots in the arch of the foot?

Not only is this probably the most perfect of all Perfect Spots, but it is also perfectlyeasy to find: it is exactly in the center of the bottom of the foot, halfway between theheel and the ball, and halfway between the inside and outside edges (perhaps slightlycloser to the inside).

http://saveyourself.ca/tutorials/plantar-fasciitis.php



The arch muscles generally feel best when pressed on an angle, for example towardsthe outside of the foot. But this is a minor point: any angle will do!

What does massaging the arch of the foot feel like?

You will know it when you feel it! Having massaged thousands of people and thou-sands of feet, I can tell you without hesitation that the center of the arch muscles is apopular, “feel good” spot. It usually produces a clear, sweet ache with mild to moder-ate thumb pressure only.

Note that despite its popularity, Perfect Spot No. 10 usually does not cause any re-ferred sensation — that’s the satisfying, spreading ache that is often associated withother significant trigger points. Don't take the lack of referred sensation to mean thatwhat you're doing isn't working!

All massage feels better when someone else does it, but this is especially true of footmassage. Although it is easy to massage your own foot (and highly recommended ifyou have no other choice), receiving a foot massage is one of life’s truly delicious ex-periences, the apple pie à la mode of touch.

What about reflexology?

Some believe that there is yet another reason why foot massage feels so good: theremay be neurological and/or energetic connections between each part of the sole of thefoot and every other region and system of the body. This is called reflexology. Reflex-ologists claim that foot massage can have a therapeutic effect on any part of the hu-man body.

This claim is extraordinary, and “extraordinary claims require extraordinary evi-dence” (Carl Sagan, Broca’s Brain, 1972). I have certainly never seen nor heard of suchevidence, although (to quote another old chestnut of skepticism) “absence of evidenceis not evidence of absence.” The phenomenon may exist, whether there is clear evi-dence for it or not. However, it is most likely that the profound sensations of foot mas-sage simply gave someone the idea that foot massage was unusually important.

I have no trouble with the general idea of therapeutically significant connections be-tween body parts, or even with the particular idea that massaging the foot could affectorgans and systems. That is plausible.



I doubt, however, that the average colourful reflexology “map” is 100% accurate — atleast, not compared to the average textbook anatomy diagram. If the connections existat all, they are probably subtle, and there is probably significant natural variation be-tween individuals. Only a study of a large number of carefully compared observa-tions by several extremely skilled and knowledgeable practitioners could hope to con-firm that stimulating a certain tiny spot on the foot has a therapeutic effect on a cer-tain organ — and even then it wouldn’t necessarily be true of every person.

My own personal experience with reflexology is that it feels as good as any other footmassage, but no better, and has no apparent additional therapeutic effect. Still, a footmassage is always a pleasant experience in and of itself.





The Perfect Spots are based on a decade of my own clinical experience as a massagetherapist, 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 …
















This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest riband your spine — right where the stability of the rib cage gives way to the relative in-stability of the lumbar spine. Muscle tends to bunch up around this joint between thelast of the thoracic vertebrae and the first of the lumbar. The sweet spot consists oftrigger 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.

































7Perfect Spot No. 7 — Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syn-drome



related to: bruxism,headache, jaw clenching,TMJ syndrome, toothache,tinnitus

muscle(s): masseter
















10THIS PAGE (Perfect Spot No. 10 — Massage Therapy for Tired Feet (and PlantarFasciitis!))











for pain: anywhere in the upper back,mainly between the shoulder blades

related to: scoliosis muscle(s): erector spinaemuscle group











Notes

1. Basmajian et al. The Role of Muscles in Arch Support of the Foot. Journal of Bone& Joint Surgery. 1963. PubMed #14077983. BACK TO TEXT

2. Thordarson et al. Dynamic support of the human longitudinal arch: a biomechan-ical evaluation. Clin Orthop. 1995. PubMed #7634700. BACK TO TEXT





http://saveyourself.ca/bibliography.php?bas0


http://saveyourself.ca/bibliography.php?tho


massage therapy for bruxism, tmj syndrome

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