For years, I accepted pain as the price to pay for doing massage—until I had so many pain issues that I seriously contemplated reducing the size of my practice. It was then that I took a long, hard look at what might be causing or exacerbating my pain issues. Over the course of the next year, my massage room became my lab and I discovered that if I followed five basic strategies to reduce or eliminate pain, I wouldn’t have to lose one client. In fact, I grew my business.  

Strategy #1
Avoid Moves That Hurt
It seems fairly straightforward that you should immediately stop doing a massage technique that hurts you; of course, it’s slightly more complicated than that. For one, some massage modalities frown on technique modification as sacrilege. If you follow such a modality, you’ll have to decide for yourself whether you think modifying or changing a massage technique will affect the treatment outcome. From my experience as a neuromuscular massage therapist, I’ve found that I can still get the job done even when I amend or change a neuromuscular technique.
Other times, an MT fails to see that a massage technique is hurting her body because she’s locked into a routine. Tara, a massage therapist who was looking to get back into massage on a part-time basis, told me she was worried about aggravating her shoulder pain that was nearly debilitating when she was a full-time MT. I asked her to pay attention to her shoulder as she worked on me. When she did a subscapularis release on me, she felt that scary pain in her shoulder.    
So, I showed her a different subscapularis technique. She performed the technique on me and felt no pain in her shoulder. She was slightly embarrassed when she realized the solution to her shoulder pain while doing massage was to simply stop doing the technique that triggered her shoulder pain. The reality is we all get locked into routines, and sometimes it takes an outside observer to point out how something in a routine might be hurting us.

Strategy #2
Use Your Tools
One sure way to start and continue experiencing pain is to be a one-trick pony. It’s all too easy for an MT to over-rely on and overuse one tool (finger, thumb, knuckle, fist, elbow/forearm). For example, often an MT will develop problems with her thumbs because thumbs are perfect for both deep pressure and detail work. But, if an MT doesn’t get comfortable with using a different tool for deep pressure (like an elbow or knuckle), or doesn’t incorporate a different tool into detail work (like fingers or a hand-held tool), the thumbs will probably continue to hurt.
I can attest to this. Early in my career, I used my thumbs for everything, including squeezing, which really made them ache. So, over the next few months, I experimented with a two-handed technique. Instead of squeezing a muscle (e.g., trapezius) between the thumb and fingers of one hand like I normally did, I started squeezing it between the fingers of both hands. The results were amazing: my thumbs stopped aching and I discovered I could actually deliver deeper pressure with less effort this way.
In addition to over-relying on one tool, we tend to overuse our dominant side. If you’re right handed, this means your right thumb, knuckles, and elbow are going to get more use than your left thumb, knuckles, and elbows. If you have a dominant-side pain issue, try using the tools on your nondominant side more frequently. Incrementally make the change. The more reps you get in, the more comfortable you’ll get, and, eventually, you’ll be able to even out the workload. This switch will give your fingers, thumbs, knuckles, and elbow/forearm on your dominant side a chance to rest and heal.  

Strategy #3
Switch Tools
Using pain as a guide to make an adjustment, don’t be afraid to switch tools in the middle of a stroke. For instance, I may start a back stroke with a thumb at the shoulders, but if my thumb starts to bother me in the middle of the stroke, I will immediately switch to a knuckle braced by a fist. Or, if I want to continue to use my thumb to pick up tight areas, but I don’t want to stress my thumb, I will brace it with a knuckle and transmit the deeper pressure (if needed) through my knuckle.  

Strategy #4
Adjust Table Height
If your pain areas involve neck, shoulders, arms, and/or hands, lowering the table height for deep pressure can be a game changer. For me, it was the key move that made my shoulders (right AC joint and left shoulder capsule) happy again. Lowering the table will allow you to use your body weight to generate pressure without taxing your upper body. How low you set your table will depend on the pressure depth requested for the massage, the primary tool that will be used for the massage, the client’s size, and the area of focus.
First, find out what kind of pressure your client wants. Deep pressure requires you to lean into the table with most, if not all, of your weight. So, for deep pressure, your table will be set lower than it would be for light pressure, which requires a minimal lean.
Next, decide which tool will be your primary tool for deep pressure. Is it going to be elbows/forearms, thumbs, or knuckles? In order to lean with all your body weight, thumbs and knuckles will require a lower table height than elbows/forearms.
Is there a specific area that needs deep pressure? If so, this may further affect table height. Picture your massage table with a person lying face down. Now imagine the person’s body is a contour map. The highest parts on the prone-body contour map are typically thoracic back and glutes. If you’re going to focus on the thoracic back or glutes (or both), you’ll want your table low enough so you can lean your full weight into these areas without having to push with your arms and shoulders.
Lastly, the size of the person will affect table height, too. In terms of the prone-body contour map, a large person’s thoracic area is going to rise off the table higher than a small person’s thoracic area. If a big person requests a deep thoracic back massage, your table should be lower than it would be for a small person who requests a deep thoracic back massage.
Whether you’re leaning in with an elbow or barred thumbs, your lower back should always be neutral, not flexed or hyperextended. To maintain lower-back neutrality when leaning, I periodically lift my rib cage up as I breathe in, then slightly suck in my lower abdomen to make sure my back is straight. If your table is too low, you may start to feel pain in your lower back. That’s a sign your table needs to come up a notch. Everyone’s experience is a little different. Experiment with table heights while performing deep pressure to determine what works best for you.

Strategy #5
Change Positions
Massage, like dentistry, has repetitive positions built into it. For instance, a dentist looks down at the patient when working and, typically, so does a massage therapist. Constantly looking down can take a toll on, or aggravate, neck and back conditions, like it did with me.  
But there is a big difference between repetitive positions in dentistry and massage therapy: MTs can change positions, whereas dentists are locked into positions. For instance, a massage therapist doesn’t actually have to look down all the time to do her work. Instead, she can keep her neck neutral by looking straight ahead. My neck pain was practically eliminated through the combination of maintaining a neutral neck for most of a massage and lowering the table when doing deep pressure.
Looking straight ahead when giving a massage may seem awkward at first, but if you stick with it, you’ll experience an additional benefit besides pain reduction: you’ll improve your palpation skills. Why? Because not looking at the tissue under your fingertips forces you to pay closer attention to what’s under your fingertips. My only words of caution are to choose carefully when you decide not to look down. Looking straight ahead can look strange to a supine client with his eyes open, and if you’re working around the waist or chest you don’t want to errantly stray beyond an ethical boundary.
Wisely adjusting stances can help us avoid repetitive stress issues. When I stay in the same stance throughout a massage, I start to feel nagging pains. For instance, a wide stance tends to produce pain on the left side of my foot and eventually will bother my right hip. However, when I regularly switch my lead foot in a stance or switch stances entirely, I usually feel no pain. Switching stances may sound disruptive to the massage but—just like tool transitioning—as long as you’re maintaining the same pressure as you switch stances, the changes are practically imperceptible.

Ease the Pain
Pain doesn’t mean you have to stop doing massage or even that you’ve reached your massage limit. It means adjustments need to be made. First, make and prioritize a list of your pain areas. Then, try eliminating any move or technique that causes or aggravates a pain condition. Next, check to see if your pain is related to over-relying on and/or overusing a tool. If so, get comfortable with a substitute tool. Also, if a pain area is aggravated in the middle of a stroke, try pausing and switching tools. For neck, shoulder, arm, and hand pain, make sure your table is low enough so you can lean to generate deep pressure instead of relying on your upper-body strength. Finally, don’t forget to look straight ahead to keep your neck neutral and frequently switch up your stances to avoid pain from repetitive stress postures. The sooner you change the pain, the faster you can grow and enjoy your practice.

Create a Checklist
Where are your pain areas? Pay careful attention to your body and create a pain list. Just note areas in your body that hurt during or after a massage. If your list is getting long, don’t get nervous. My partial list at the time I started my experiment included the left side of my neck, right acromioclavicular (AC) joint, left shoulder capsule, and left elbow. A lot of my pain areas diminished or disappeared after I made one or two key adjustments.  
Next, prioritize your list. What needs to be addressed right now for you to not hurt when you do your next massage? For me, the left side of my neck (probably related to an old football injury and exacerbated by doing massage) was a priority because the low-grade, occasional neck pain had turned into a sharp, almost constant pain.
Your list may change once you start to work on it. That’s OK. The important thing is to identify the top pain areas so you can begin to apply these pain-reduction strategies.

Integrating Tools
Tool changes within the same stroke may seem like they would be messy, but they’re not, especially if you slow down your stroke. In fact, when I make a tool change during a stroke, I often stop.
When experimenting on other MTs, I learned that the pause didn’t feel awkward to them as long as I maintained the same pressure in all facets of the tool transition.
Here’s an example of a smooth tool transition: I’m gliding with my right thumb, but it starts to hurt. I stop the stroke and place the middle knuckle of my left hand down, exerting the same pressure as I am with my right thumb. I lift off my right thumb and continue the glide with my left knuckle.

Mark Liskey is a massage therapist of 24 years, teacher (www.themassageinstitute.net), and business owner (www.pressureperfectmassage.com). His blog at www.makethemostofmassage.com provides massage therapists with the extra knowledge and specific tools they need to succeed in massage.