Trigger points (TrPs), or muscle “knots,” are a common cause of stubborn & strange aches & pains, and yet they are under-diagnosed. The 14 Perfect Spots (jump to list below) are trigger points that are common & yet fairly easy to self-treat with massage — the most satisfying & useful places to apply pressure to muscle. For tough cases, see the advanced trigger point therapy guide.
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.
Unlike trigger points in the back or the shoulders, where feelings of aching and stiffness are all-too-familiar, people are often unaware that there is anything wrong in their forearm until things get ugly. Unfortunately, instead of being diagnosed correctly, almost everyone who develops an active Spot No. 5 is diagnosed with either “tennis elbow” or a wrist problem, usually carpal tunnel syndrome. Note that not every Perfect Spot is a major cause of common problems in the area — I do not blindly assume that every muscle knot is clinically significant! But this one often is.
The unholy relationship between Perfect Spot No. 5, wrist pain and carpal tunnel syndrome
Virtually all wrist pain is either caused or significantly complicated by myofascial TrPs in the forearm musculature, especially the extensors of the wrist and fingers, and especially Perfect Spot No. 5.
(Of course, injuries are an exception, right? Sadly, no. The “cause or complicate” rule applies even with injuries: if you damage your wrist, tension in the forearm is going to be a factor in healing.)
Unless there is a clear injury, nearly all kinds of wrist pain, regardless of their true cause, are usually mistaken for carpal tunnel syndrome. Carpal tunnel syndrome is one of those conditions that enjoys such a grandiose reputation, such over-the-top “popularity,” that it is usually suspected and diagnosed no matter how wrong the symptoms are. Something wrong with your wrist? Must be carpal tunnel syndrome!
The One True Cause of most wrist pain, however, is Spot No. 5!
I say that with my tongue in my cheek, of course — there’s never one true cause of anything. Nevertheless, Spot No. 5 is a contender because, even when it is not the actual cause of wrist pain, it is often such a significant complication that relieving it will come close to solving the problem. In fact, even in cases of actual carpal tunnel syndrome, where all the signs and symptoms really do fit with a diagnosis of carpal tunnel syndrome, treating trigger points in the forearm often resolves the problem — somehow, relieving them interrupts whatever vicious cycle it is that perpetuates carpal tunnel syndrome.
Spot No. 5’s dramatic tennis elbow connection
Perfect Spot No. 5 is probably 1 a major cause of or contributor to a “tennis elbow,” technically known as lateral epicondylitis, which commonly afflicts typists as well as racquet sports players. Just like “carpal tunnel syndrome” often isn’t really carpal tunnel syndrome, “tennis elbow” often isn’t really tennis elbow. Tennis elbow is regarded by most health care professionals as being a tendinitis2 of the common extensor tendon at the elbow — immediately to the “North” of Perfect Spot No. 5.
But tennis elbow is rarely if ever a case of true or “pure” tendinitis, because there isn’t actually much inflammation involved. True inflammation is only present in the early stages of tendinitis — anything that lasts longer is not really inflammatory in nature.3 In 1999, Boyer and Hastings wrote, “The term epicondylitis suggests an inflammatory cause; however, in all but one publication … no evidence of acute or chronic inflammation is found.”4
Instead, tennis elbow is entirely the result of either the pain of TrPs themselves, or due to the fact that muscle knots are pulling hard on the tendon. Regardless, the quickest path to relief in almost all cases of wrist and elbow pain is to massage Perfect Spot No. 5. Self-treating them is a low-cost, low-risk method of attempting treatment of tennis elbow. For more information, see the tennis elbow tutorial.
Tennis is the traditional way to get a case of tennis elbow, but it is not actually the most common. Keyboard usage is undoubtedly by far the more common cause of the condition these days.
And a (strange) scalene muscle connection with Spot No. 5 and tennis elbow
Curiously, a muscle in the neck seems to have an unusually strong effect on Perfect Spot No. 5. Travell and Simons write, “Scalene muscle trigger points are frequently the key to [treatment of] forearm extensor digitorum trigger points.”5 If you need to help your forearm muscles, I recommend also treating your scalene muscles — see Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain.
How to find and treat Perfect Spot No. 5
The muscles on the back of your forearm lift your fingers and wrist. You can see them moving under the skin of your arm if you drum your fingers on a desk. In writing, typing, and mousing, these muscles must hold the wrist up and stable, and the fingers work constantly. In racquet sports, the forearm muscles particularly suffer because of the eccentric contraction required to stabilize the wrist on striking.6
Spot 5 is easy to find and treat yourself. Simply find the bony knob on the outside edge of your elbow. This is the point on which all the muscles on the back of your arm converge. Just beyond that point — below it, towards the wrist — you can easily find the thick bundle of tissue that is the “common extensor tendon.” Perfect Spot No. 5 is just a little further down, as the tendon turns into muscle.
Here’s another way of visualizing the location: imagine a wrist watch that you're wearing really high on your arm ... almost at your elbow, but not quite. About and inch or two away. Perfect spot #5 is about where the face of the watch would be if you were wearing a watch that high on the arm.
Perfect Spot No. 5 is one of those Perfect Spots that is not alone in the area. You can find significant TrPs nearly anywhere in the muscles on the back of the forearm! Perfect Spot No. 5 is simply the best of the lot.
An easy way to self-treat this spot is to press it into a hard surface — the rounded edge of a counter top is about the right height and shape. It won’t take much experimentation for you to figure out exactly where to press! As always, go slow and easy at first to avoid aggravating it.
The Tiger Tail Rolling Muscle Massager
The Tiger Tail Rolling Muscle Massager (made by Polar Fusion, in Washington state) is terrific for self-massage of the arms and legs, and I’ve used it mostly for my shins over the past year. And then I learned that I’ve been missing an “obvious” and lovely way of using it to massage the forearms as well: just brace one end on the hip, hold the other with one hand, and then moving the other arm across the roller. Suddenly it’s my new best friend! My forearms are chronically exhausted by long days of typing.
It is really just a specialized rolling pin, made for squishing muscle instead of dough. There is no question that I thought of (and tried) using an actual rolling pin for self-massage long, long before I’d heard of the Tiger Tail. But a rolling pin tends to be too hard, too broad, and too fragile (the handles tend not to be sturdy enough, unless you’ve got a really good quality rolling pin) for most massage purposes. The Tiger Tail solves these issues: it’s got a foam cover on a narrow cylinder, and it’s extremely sturdy.