Complete Guide to Pain Relief From Trigger Points In Back

man with low back trigger point pain

Do you have low back pain?

​Wonder whether the pain is due to trigger points (or commonly known as ‘muscle knots’)?

Looking for the best way to treat these problems, which can include myofascial pain syndrome (mps) pain therapy? 

If you answered yes to any of these questions, this practical complete guide to treating lumbar myofascial pain is for you. Can myofascial pain syndrome be cured? With the right strategies, you'll be able to control myofascial pain disorder symptoms and take back your health. 

Not only will you learn how to find and treat your own muscle knots coming from soft tissue pain syndrome pain, you'll be shown how to treat lower back pain and the lower back exercises for strengthening and stretching. These exercises have worked for my patients over the last 20 years, and may help avoid the use of myofascial pain syndrome treatment medication. 

Finally, you'll be shown how to prevent lower back pain with specific prevention strategies that you can begin with today to help relieve your back pain. (Chronic myofascial pain syndrome diet is not included and beyond the scope of this article)

Want to learn more about trigger points first? You can read our article 'Introduction to Myofascial Trigger Points'. It will provide you with all the information you need to know what a trigger point is. Simply click here to go to that article. 

My patients often ask me, ‘why are trigger points so important in low back pain?’ The answer is, they’re one of the most common causes of low back pain (And most often don't require aggressive trigger shot injections).In fact, one study found that out of 126 chronic back pain patients that visited a pain center, 63.5% had what we call Myofascial Pain Syndrome. Myofascial Pain Syndrome is the diagnosis given by health professionals that is made up of trigger points. Since they’re so common, we’re going to show you exactly how to target them  with myofascitis treatment for muscle or fascia back pain relief.

Note: Myofascial pain syndrome and fibromyalgia are two different conditions, yet they can sometimes overlap in pain and symptoms. It's not rare to have someone with myofascial pain syndrome disability and realize later that they have fibromyalgia instead. Treatments may be different. ​


Why Is The Lower Back Trigger Point Pain So Difficult To Treat?

There are a few reasons why these trigger points are so difficult to treat (and don't require any scary things like myofascial surgery!), even though they are so common:

  1. 1

    The source of pain is not always close to the painful area

    Have you ever found yourself poking around trying to find the pain, but for some reason can’t seem to locate it? In our other article on neck pain for example, 'scalene' myofascial pain syndrome consists of pain going all the way down the arm and into the hands, yet the cause was in a small myofascial pain (mp) muscle in the front of the neck. That’s what trigger points do. In some cases, you’ll find that the muscle knot is right where the pain is. In other cases (sometimes called diffuse pain syndrome), the origin of pain is a short distance away. For example, your low back pain may come from the mid back, or even the buttock area. No wonder they’re difficult to treat! A patient with a dorsal myofascial strain in the back can actually send pain down to the back of the thigh. Here is a list of muscles that can cause low back pain. Don’t worry about the names of the muscles. Just look at where they are located. For example, a 'quadratus lumborum' muscle can be the cause of trigger points for hip pain:

    Muscle

    Location

    Deep Spinal Muscles

    low back

    Superficial spinal muscles

    low back

    Quadratus Lumborum

    low back

    Gluteus Medius

    buttocks

    Gluteus Maximus

    buttocks

    Gluteus Minimus

    buttocks

    Psoas and Iliacus Muscles

    Front inner thigh

    Rectus Abdominus Muscle

    stomach area

    Soleus Muscle

    Pelvic Floor Muscles

    lower leg

    pelvic area

2

A 'diagnosis' label can make everyone overlook trigger points

Sometimes, the diagnosis is so focused on the structures in the area of pain, that we tend to forget about all these trigger points. Have you been given a diagnosis but still haven’t had any relief with your back pain? A patient of mine once mentioned that the last thing they cared about was the fancy names of trigger points in neck symptoms they were getting. They just wanted to know how to get rid of their trigger points in neck and shoulders, and less on overcomplicating things. Check out some of the following diagnosis that may have part or all of their pain coming from trigger points:

Diagnosis

lumbar strain

facet syndrome

disc herniation

sacroiliac joint dysfunction

spondylolisthesis

spondylolysis

osteoarthritis

These are all conditions that may be seen on x-ray, an MRI, or through a clinician’s examination. So why don’t health professionals look for a trigger release point? Well, I’d like to think that most do. However, if your doctor or therapist just diagnosed you with arthritis, they may be so focused on treating that ‘joint’ that they may not give muscle knots much thought. Whether it's trigger points legs pain, trigger points hip pain, or trigger points arm pain, there is hope. The good news is, muscle knots can have common signs and symptoms that may give you a clue that your pain has a trigger point component to it, whether it's low back, or a trigger point, neck and shoulder. That’s what we’re going to talk about next:


Common Lower Back Pain Symptoms

  • Pain is fairly similar to neck muscle trigger points. The pain from trigger points in muscles is most commonly described as a dull or deep ache. However, the pain may also be sharp when you're moving. Patients and health professionals alike (even including me) tend to believe that sharp pain upon movement is a joint problem. We are just as guilty of jumping to conclusions on where the real pain is coming from if we're not careful.  
  •  You may drop down on all fours when the pain becomes excruciating. Sometimes, people with low back trigger points (foot pain from the back being rare) tend to brace their back as they are standing, or standing from a sitting position. Trigger points in hip muscles can further complicate the issue. 
  • Coughing and sneezing  can also be painful to the point that you may think you’re going to fracture a rib. There’s one muscle, the quadratus lumborum, that attaches to the bottom rib. If there is an active trigger point here, you’ll experience intense pain every time you cough, sneeze or take a deep breath in. Trigger points in shoulder and neck rarely have the same issues. 
  • You can have pain going down your leg. Most of the time, this only goes down to the back of the thigh (just like shoulder pain pressure points can send pain down the arm). This often makes people jump to the conclusion that they’re suffering from sciatica or nerve problems. Please note that nerve problems are not that common, but we tend to easily shift blame to them. This may more to do with the intensity of the pain. The more intense the pain, the more we believe that it’s something serious, like a nerve problem. Upper back pressure points that refer pain to the arms can also be mistaken for 'nerve pain'. 
Mind map of key facts about muscle pain

How Do I Find Trigger Points That Cause Low Back Pain?

Most of the trigger points are located in the back area, extending from the midback and into the buttocks. There are some, as we’ve seen, in the front of the body, like the stomach and inner hip area. To make treating your muscle pain easier, I like to divide the body into sections. In the upper body, you can divide sections into jaw trigger points, facial trigger points, scapula trigger point, etc. In other areas, you can divide one area into several, like trigger point, knee area can be the front, back, inside, outside, up and below the knee. Let’s look at each section in the back area and the key things you need to know:

Finding Trigger Points In The Back Area:

The low back is the best place to start looking if our goal is getting rid of trigger points. The trigger points here are mostly local in nature. That means the pain is local to where you find the knot. What causes trigger points to develop here can be one of many different issues. However, surprisingly, the most common source of trigger point pain in the low back is in the buttocks. In chiropractic, trigger points in this location are never missed. We’ll get to that next.

For now, finding trigger points in the low back area is quite easy (and don't require an injection!). Muscle spots here are generally difficult to find with the hands. You may not be able to reach the spot, or the muscle thickness may be too great to be able to dig in with your fingers. Even as an injection point, the area is too thick sometimes. 

The best tools to use for back knots symptoms are either trigger point balls or the Muscle Wizard (low back is second only to how effective it is for trap trigger points). Let’s discuss both of them next. Here’s a video of using a trigger point ball for low back muscle pain:

With a trigger point ball, simply stand against a wall and slide a ball slightly to the side of the spine.

​Side Note: Balls are really versatile. Apart from trigger point jaw pain, trigger points in chest, neck pain pressure points, and shoulder pressure points can all be helped with a simple trigger point ball. Now back to the instructions:

You want to make sure you start about half way up the spine. To be more exact, we usually start near the bottom ribs, but anywhere in the middle of the back should be fine. The path I like to use is start slightly to the side of the spine and then slowly slide the ball down until you reach the low back area. Then repeat on the other side. Don't be too concerned with what causes muscle knots in back. Just focus on finding the spots and treating them. For example, for elbow trigger points, my patients know not to focus on all the complex nerves, muscles, tendons and ligaments that are there. They just know to find a knotted muscle and press on it. 

Remember, you’ll need to find all the trigger points. And we haven't even gotten to gluteus medius trigger points, not to mention the other smaller and larger trigger points in buttocks! Once you finish both sides, move back to the first spot and now place the ball slightly more to the side of the first spot. Repeat the whole process again. This is much easier than getting a shot for muscle pain. Some of my patients describe this as "plowing the field". You go up and down the back and then move outwards and repeat. To visualize how simple this is, imagine if you were doing acupuncture for trigger points. You can only imagine how many needles you'd need to get to all the muscular knots! Or even how many injections from a trigger shot for pain. Pretty soon, you’ll hit all the pressure points for back pain, without giving any thought to the causes of muscle knots. Just find the stress knots, apply pressure, feel the ease in pain and move to the next. 

Note: I mention a few times about injection for muscle pain. It's because it's one of the most common questions I get, and one of the most common answers is that it's often not required. ​

You can also use the trigger ball while lying down. I usually prefer you start standing because it gives you more leverage for the amount of pressure you want to apply. Its more difficult to do that lying down (although lying down I can hit myofascial neck pain points as well). Most people tend to apply too much pressure (their body weight) over their lumbar trigger points. Treating muscle knots like this may leave you feeling tensed up, which is the last thing you want to do. Also make sure you breath deeply as you apply pressure to the low back, buttocks and hip pain trigger points. It's an important part of your muscle knot treatment.


Aside from the tp therapy ball, another effective tool for knots in back symptoms (without resorting to hundreds of acupuncture trigger points needles!) is the Muscle Wizard. Check out the following video on how to target painful muscle knots in the low back with the Muscle Wizard:

muscle wizard low back trigger point tool

With the Muscle Wizard, you’re able to target 4 spots at once, 2 on each side of the low back. The benefits of using the Muscle Wizard is that you can control the amount of pressure you want to provide. It’s very easy to apply less pressure if you’re just getting started, and more intense pressure as you begin to see pain relief.

Apart from trigger points head area, while reducing the chances of getting trigger shots for back pain, the Muscle Wizard can be used for forearm trigger points, trigger points for shoulder pain, myofascial cervical strain, and more. I've had a few patients that avoided muscle injections for pain while using the Muscle Wizard. ​

You can also use it while sitting, lying down, and even standing (standing is an excellent position to use it for trigger point in calf muscles). Simply wrap the strap around the back knots pain areas (the area of pressure points to cause pain from) and the other end across your knee. You can then easily press your knee down, which increases pressure on your back. It’s hands free and allows you to quickly target all areas of the low back. 

Aside: For trigger points in neck muscles, one end is on trigger points neck area, and the other area is around the knee. For neck (cervical myofascial pain syndrome) the best position is sitting comfortably in a chair. ​

muscle wizard for low back pain

Finding Trigger Points In The Buttock Area:

anatomy of low back muscles

Most people think that the buttock is one big muscle. In fact, there are several muscles in the area, such as the gluteus minimus trigger points, and they can all give you different types of pain symptoms. However, you don’t need to concern yourself with each and every muscle. The key is to get a general overview of how to look for trigger points so you can spend more time treating them yourself.

Most people have lower back pain above buttocks. You can target your buttock pain using a trigger ball, Muscle Wizard or tp therapy roller. If you’re using a trigger ball, you can start off the same way as you approached the low back. With ball in hand, trigger points can be targeted by starting slightly next to the middle of the buttocks. (Same principles can apply to chest trigger points). This time, slowly begin sliding the ball outwards instead of down. Once you get to the outside of the buttocks (near the hip area), come back to near the midline but slightly lower. Then repeat the same process. Have patience with the buttocks but don't overlook them. For muscle knots in back, symptoms can reproduce hip pain and buttock pain. Even if you were only thinking of focusing on the back, chronic muscle knots are probably the most common area to target. 

A foam roller can also find trigger points, but its’ more of a general tool. Again, instead of focusing on what causes knots in muscles, the goal is to find a tender spot and hold that position for a few seconds, rather than constantly rolling up and down the glutes. Also make sure that you do not hyperextend your low back as you’re rolling on the foam roller. For muscle knots, causes are secondary to actually taking action and doing the work with your tp therapy foam roller. 


Finding Trigger Points In The Abdominal Area:

Diagram of the abdominal area and key muscles

In the abdominal area, there are two different areas that you want to target (and don't even think I can imagine trigger point injections in this area!) With a good knowledge of trigger points in hand and knowing full well you don't need tpi injections, let’s start with the psoas. This is a muscle that attaches to the low back (mirrors the quadratus lumborum trigger points in the back), goes through the stomach and attaches to the pubic bone in the front. It basically crosses your body from the back to the front. Whereas for things like shoulder pain, trigger points can be treated by may different tools, the psoas can easily be treated with the hands.

I usually don’t recommend any tool for the muscle nodules in this area. The reason is simple. Apart from knots in muscles, there are a lot of different structures in this area. You just may not feel the pulse of the aorta artery if you use a tool, even with a trigger point. The aorta artery can sometimes mimic these painful pressure points, so one needs to be careful as possible to only target lower back pain pressure points and not the artery. 

abdominal muscle anatomy

You can also feel pain in the back from the rectus abdominal muscle. These are slightly to the side of the midline. The most common back pain knots are just under where the sternum ends, while others are all the way to the bottom where your abs attach to your pubic bone. What causes muscle knots here can be many different causes, such as posture, stress, strain, etc. This is best targeted using your hands, and instead of trigger points on feet standing, do it lying down, as demonstrated in the following video:

We can also use the "plowing the field" technique with the abdominal muscle back pain pressure points. Start at the top and move down in a straight line, searching for those muscle knots. Then move slightly more out from the midline  in treating trigger points and repeat again. Make sure you treat both sides. I always keep the legs as straight as possible. Some of my patients tend to flatten their back when they keep their knees up, thereby shortening the muscle. Keeping the knees straight usually allows you to target them easily. However, play around with both positions. Surprisingly, the plowing the field technique is so effective that I use them in trigger points in head muscles also. I find trigger points on head muscle by doing the same technique, although the area is much smaller. 

Remember, the goal is to find a spot that is referring pain to the back. Use your hands to differentiate between what is a muscle knot and an artery. Most people will have some sort of tenderness in these muscles. What we really want is to recreate the back pain and then target these abdominal trigger points until the pain goes away. Then we can also focus on lower back trigger points, buttock areas, and more. 


What's The Best Way To Treat Lower Back Pain?

Now you’ve figured out how to find these trigger points. Face the fact that the next step is to actually figure out how to treat them. Here are a few key points to remember, without resorting to muscle injections:

  • Don't press too hard.  If you’re grimacing in pain or tensing up (example: in buttocks), the trigger points in glutes will resist the need to relax. Apply enough pressure that you feel the tenderness or referral of pain, but your body is completely relaxed. Pressing too hard is what causes trigger points to resist relaxing. When the pain gradually begins to improve, you can gradually increase the pressure. Apply pressure for about 30 seconds to a minute. On a side note: if you require more time, either move on or realize it may be something else (in some cases, myofascial, fibromyalgia pain can feel similar but sometimes require drastically different treatment approaches.)
  • Over-treating a muscle is just as bad as pressing too hard. Your goal is to try to target as many trigger points as you can in one self-treatment session without resorting to tpi injection. Sometimes we find one spot and end up staying there for the entire session. We begin to think that the more we treat that one spot, the faster its’ going to get better. I had one patient that couldn't stop pressing into their bicep trigger points, and then couldn't figure out why it always felt sore and 'swollen'. He thought treating this, in addition to his mid back trigger points, was going to make things get better faster. That’s rarely the case. It’s more effective to spend a session treating all the trigger points than it is to stick to one spot. If you over treat one spot, there is a risk of feeling sore or bruised the next day.
  • Be careful of other structures in the area (like arteries when dealing with thigh trigger points). This is particularly true for self-treating the psoas muscle. There are a lot of other structures on top of this muscle (my physician colleagues are also careful with an injection for muscle spasm in this area). I sometimes even question whether we’re actually targeting the psoas muscle or not. If you feel a pulse, you’re most likely going over the aorta artery. If that happens, you want to slide further to the side until you can’t feel a pulse. That’s another reason why I usually prefer to use the hands for a psoas trigger point. Once you go further down, like into quad trigger points in the thigh, you can begin to use other tools. 
  • In the buttock area, there’s a muscle called the piriformis. The sciatic nerve runs under this muscle. If you treat this area too aggressively, you’ll begin to notice a tingling and numbness going down the leg. If the tingling goes below your knee and into your foot, you are most likely irritating your sciatic nerve. Move off that area until the tingling stops. You are not likely to damage the nerve if you do accidentally irritate it. Just don’t keep doing it! (If one gets injections for fibromyalgia, one always has to consider these spots so not to confuse the pain sources)
  • You will rarely feel a 'knot'. Focus on finding a tender spot that is recreating your low back pain. Health professionals focus more on things such as the ‘twitch response’ etc. You don’t need to worry about this. Keep it simple. You may feel a trigger point in an area that feels completely relaxed. You may even question whether there’s a trigger point here. Sometimes the most relaxed muscle can have the most severe trigger point. I, to this day, have never felt calf trigger points being 'tight' since most peoples' calves are tight to begin with! Don't even get started on foot trigger points. The trigger points in feet are hard to differentiate with your hands. To extend that to different conditions, fibromyalgia and myofascial pain is similar, but even there, you may think you have found a trigger point but not know it's actually fibromyalgia you are dealing with. At the end of the day, whether its the back or shoulder blade trigger points, focus more on the whether you found body trigger points that ACT like it. 

Best Stretching Exercises For Lower Back Pain

With any trigger points in the back, its best to use self-treatments or therapy to first get pain relief. Once you do that, you can start a program on stretching for lower back pain. We’re going to go through several different stretches for the low back, psoas and buttock area. The question is, where do you start? First, identify which section is actually giving you myofascial release trigger points pain. Then begin stretching that area (unless you're treating ear trigger points, where stretching may not be the best advice! Nor using a foam roller trigger). Let’s look at the different areas:

muscle wizard trigger point tool

Lower Back Stretches For Pain:

Surprisingly, most of my patients feel there’s one back muscle. That’s an honest mistake since that’s pretty much all you see when you look at a back! However, there are several layers of muscles, and they all expand out into different directions. So if you did an exercise in one direction, you’re missing all the other tight muscle fibers

That’s why one of the best stretches I’ve given my patients over the years is what we call the QL stretch. QL stands for the name of the muscle ‘Quadratus Lumborum’. This is the bright red muscle in the image. To be honest, it probably stretches a lot of different back muscles and not just the QL. But we health professionals love to give things specific labels! You can do it standing or sitting.​ The 2 videos above show you how to stretch this muscle. 

anatomy of low back muscles

Stretches For The Buttock Area:

The buttock area is probably the most common area for gluteal trigger points that refer pain to the back. The stretches here are simple to do. You want to be careful and not overdo the stretching part of this program. If you feel more pain or discomfort from stretching, stop it and go back to self-trigger point treatments. Once the pain improves, you can begin stretching again.

Woman laying down and stretching her buttock and lower back by bringing her knees up to her chest

There are times when my patients had to stop the stretching part of their program several times before they were able to do it without pain in their gluteus maximus trigger points, as an example.

Don’t look at it as not working. Look at it as a learning experience. Learn from your initial failure, go back to self-treatments and gradually go back.

Over time, you’ll be able to easily stretch without pain.


Stretches For The Abdominal Area:

Woman in pink performing the lunch stretch for the hip flexor muscle

The abdominal area primarily consists of the psoas muscle. This is the hip flexor muscle. There are two ways to do this stretch.

The one associated with the image in this section is the more difficult one.

My recommendation, if you are overcoming trigger point pain, is to do the easiest one first. Sometimes this is all you will need. 

Both are demonstrated in the video above. The easiest one requires you to lie with feet up, and simply flatten your back. You'd be surprised how effective this simple exercise can be!​


Best Lower Back Strengthening Exercises

Strengthening is probably the most important exercise you can do for the long term. There are certain muscles in the body that respond better to strengthening after myofascial injury, while others respond better to stretching. I’ve found more of my patients get pain relief from strengthening their lower back than from stretching. We'll go through some of the reasons below. First, watch this short video as I demonstrate some of the common low back strengthening exercises for the low back:

Woman in blue performing the plank strengthening exercise

When we talk about strengthening, we aren’t talking about getting ‘bigger’.

The goal of your strengthening program is to build up endurance. Our back is constantly active all day to hold us in position.

When they don’t have enough endurance, they fatigue and begin causing pain.

Man doing the leg stretches

That’s why we’re going to only focus on a couple of exercises. My patents often ask ‘are there more?’ The answer is, there’s a LOT more. However, I’ve found that simply doing these will help over 80% of the time.

Keep your program simple. If you begin to feel more pain or discomfort for trigger points in back muscles with these exercises, stop. Go back to self-treatments and / or stretching (if you’ve already found that stretching doesn’t increase your pain or discomfort). Then gradually build yourself back up to the strengthening exercises.

Also, the goal isn’t to hold these positions as long as you can. The goal is to hold the position as long as you can PROPERLY. Proper form is very important with strengthening. If you are doing a strengthening exercise and find that your back is getting tired or slipping or sinking, stop. Rest for a few seconds. And repeat again. We are building up endurance.

Start with just one exercise first. You can pick any one exercise. Once you get better at that, you can move on to any other. I usually like to align the strengthening exercise with the area where you find trigger points. For example, if the problem is the low back area, I like to start with a side plank exercise. If it’s in the buttocks, I prefer to start with the bridging exercises. If the issue is in the abdominal area, I usually go with the plank exercise.

Prevention Strategies For Low Back Trigger Points

Before you begin any self-treatments, stretching or strengthening program, the simplest way to get pain relief is looking at some of the aggravating factors that may be causing your problem. I’ve learned to spend more time on a patient’s history, uncovering the way they sit and move, than I do on actually poking around trying to find the muscle knots. See if you are guilty of any of the following. If so, make changes today. You might be surprised at achieving pain relief even before you do any sort of treatments on it.

Avoid sitting for long periods of time where your knees are above the hips. Keep your feet flat on the ground. For optimal positioning, your knees should be slightly pointing down at about a 10 degree angle. Also take a look at whether your foot rest is too high. This keeps the psoas (hip flexors) chronically tight and leads to muscle knots.

Man doing the sit up exercise to strengthen his lower back - BAD for lower back pain!

Sit up exercises must be avoided at all cost! Use the plank exercises in our strengthening section instead. Excessive sit up training can activate the trigger points in the stomach area.

Your back is placed in an unsafe position, which may lead to more low back pain. The spine goes into flexion every time you do a sit up. That's the same position your back is in all day if you're sitting at work all day. That's the last position to be in.

See if you have a lower leg insufficiency. That means one leg is lower than the other. By itself, there’s some controversy whether it actually makes a difference in back pain. However, new research shows that it may affect you if you stand all day. If so, it sometimes can be improved with a proper back stretching and strengthening program. If not, then look into getting a heel lift. Make sure you go to a qualified health professional that can monitor and make sure you don’t over do it with the heel lift. The minimal difference should be at least 6 mm. Here’s a short video on the best prevention strategies if you stand all day.

  • If sleeping on the back, put a pillow under the knees to take pressure off the low back.
  • Avoid having a wallet in the back pocket. I once had a patient that was ready to go for surgery. We took his wallet out and his pain improved. This is a rare case but just goes to show you how a small change can really make a difference.
  • Keep a pillow between your knees if you’re lying on the side.
  • If you sit longer than one hour at a time, you need to take a break. Taking a break for as little as 5 minutes every hour will greatly improve your health. Its gotten so bad that they actually now call this a ‘sitting disease’. Check out our short video where I explain sitting disease and the prevention strategies you can use:
Diagram of improper sitting and position of the spine
  • Sitting and leaning to one side can aggravate and tighten some of the low back muscles. Check to see if you are doing this. If so, check to see if one arm is shorter than the other. You may be resting one arm on the armrest and leaning in the direction of the shorter arm to balance out. If this is the case, adjust each arm rest individually. You may have one pelvis that is higher than the other. For this, stretching and trigger point treatments can often help get this back to normal. If not, you may want to gradually begin putting a thin magazine under the butt side that is lower. Gradually increase the thickness until your pelvis is even. One word of caution though: This should greatly reduce your back pain. If it does not, then you’ll need to focus more on self-trigger point treatments.
  • Check to see if your mattress is firm. A saggy mattress can keep certain back muscles in constant contraction.