Few things are worse than asking a returning client how they feel after a session and having them reply: “I don’t know what you did, but my pain is much, much worse.” Every therapist I know sincerely wants to help their clients feel better, whether the treatment is geared toward relaxation or a specific injury or pain. Unfortunately, in my work as an expert witness, I have seen many cases of well-meaning therapists who have seriously injured their clients.

In one case, a therapist intended to stretch a client’s shoulder, yet pulled on the client’s arm with such force that the client needed two surgeries over the course of one year to fix the damage. In another case, a therapist’s aggressive approach to working an aching forearm left that client needing six months to recover from complete loss of strength due to nerve damage. I also know of several cases where clients presented with broken ribs as a result of overly vigorous massages.

In addition to the horrific experience, pain, disability, and expenses incurred by the clients, these cases also resulted in lawsuits, damage to the therapists’ reputations, and loss of a professional licensure to practice. In some cases, careers were prematurely ended. What might be to blame? A lack of knowledge? An inflated ego? Poor judgment? Low-quality education? Inadequate skill? It’s hard to know, but here are some guidelines to help prevent this from happening to you.

Take a Thorough History

Always take a client history, preferably face-to-face. If you are under severe time constraints, have a detailed questionnaire available for clients to fill out in advance; this will give you an opportunity to review the history and ask any necessary follow-up questions. In addition to the client’s preferences for the type of session they want, how much pressure to use, and where they want you to work, find out as much as you can about their injury history. Here are some key questions to ask:

Do You Currently Have a Pain or Injury Problem in Your Body?

Finding out if a client has any present pain or injury lets you know which areas to address with gentle pressure or caution, or to fully avoid. Follow up with questions about the pain or injury issue; the depth, number, and specificity of your questions will depend on and be informed by how extensive your training has been, as well as your experience.

Where Have You Had Pain or Injuries in Your Body in The Past?

Areas of previous injury are usually vulnerable places and warrant extra care. If a client has had on-and-off back or neck pain, these areas may need special attention.

Have You Seen a Physician About This Problem? If So, What Was/Is The Diagnosis?

If the client has seen a doctor for any pain-related issue, find out what they learned about the injury. If they have not seen a doctor, encourage them to do so. In some cases, require clients to see their physician before continuing treatment; there are serious conditions that can cause back, neck, or headache pain that need immediate medical attention. For example, severe headache pain could be the side effect of either a disk injury in the neck or a cerebral hemorrhage in the brain.

Do You Consider Yourself Very Flexible or Hypermobile?

When a person is hyperflexible, they are much more vulnerable to injury. Their ligaments are longer than they should be, resulting in unstable joints and hypermobility. If it’s genetic, they may also have a more fragile type of collagen in their connective tissue. This greater range of motion is often referred to as being “double jointed.” Hypermobility can also occur as a result of an accident. In these cases, the extreme range of motion is only present at and around the site of injury, rather than throughout the body. If there has been an injury, compare the client’s left and right sides to evaluate the difference in flexibility.

Have You Ever Dislocated Your Shoulder?

If this has happened in the client’s past, one or more of the rotator cuff tendons have likely become weakened and distended. Follow up to find out if there are any positions the client avoids out of fear of another dislocation. For example, a client may say: “I avoid putting my arm behind my back and reaching up because I’m afraid it might dislocate again.” Now you know one thing not to do.

Is There Any Part of Your Body You Don’t Want To Receive Work On?

There are many reasons a client may not want you to work on particular parts of their bodies. It may be as simple as wanting more focus on specific areas, or they may be self-conscious about their body, or even associate emotional trauma with specific areas. A client may also know that an area of their body is sensitive or painful to the touch, which could indicate there is some injured tissue in that region that has never been effectively addressed, or it could simply be an area where they hold tension. Ask a couple more questions to find out if it is an injury. Regardless of the reason, always avoid any area a client tells you they do not want touched or treated.

If the Client Has a Sprained Ankle, Always Ask, “Have You Had an X-Ray or MRI?”

You don’t want to work on a broken ankle. I once had a client almost beg me to work on his sprained ankle, as he was sure it wasn’t broken and wanted to still do a particular physical activity the following week. I insisted he get an X-ray from his doctor or an emergency room before I would consider treating the ankle. Unfortunately for him, imaging confirmed he did have a broken ankle. He thanked me for pressing him to do the right thing.

Have You Had Any Surgeries I Should Know About?

Clients may have metal plates, screws, or other surgical hardware in their neck, back, lower arm, wrist, lower leg, ankle, etc. that you will need to use care and caution with when addressing. For instance, I currently have a client who broke her radius at the wrist and has screws in her lower arm. I’ve also treated a man who has anterior shoulder pain, but also has a pacemaker with wires that need to be avoided near the surface of his upper chest and shoulder. Knowing this, I’ve adjusted my work with both accordingly.

Do You Have Any Other Medical Conditions I Should Be Aware Of?

It is always important to know what other issues, conditions, or injuries a client may be experiencing aside from the specific reason for their visit. While a concurrent medical condition may not be the focus of your treatment, it can’t be ignored. Be sure to factor in any necessary adjustments, modifications, or needed positioning.

If you need to know more about the condition to feel confident in addressing your own work, ask more questions and seek out additional resources or even referrals. For instance, one of my recent clients who came to me for back pain also had a history of blood clots and phlebitis, which put him at risk for conditions like deep vein thrombosis (DVT) or, at worst, a pulmonary embolism. So, I focused my work on his low back and used only light pressure when working his legs.

A colleague of mine was treating a woman who was undergoing chemotherapy for cancer. You’ll need to rethink and modify your use of pressure when working with clients who have or have had cancer. Familiarizing yourself with Tracy Walton’s Massage Therapy Pressure Scale is a good starting point.¹

Are You Undergoing Any Medical Treatments, Or Do You Take Any Medications Regularly That Might Make Your Body Tissues More Unstable, Weak, Or Easily Bruised?

If the client says yes, ask follow-up questions about the medical treatments and also the affected area(s) to inform your pressure and technique. It’s important to be aware of the common side effects associated with medications, including, but not limited to, aspirin, Coumadin, ibuprofen, or Plavix (also called clopidogrel).

Do You Take Any Medications That Interfere With Sensation Or Pain Perception?

When clients are taking medications like Celebrex, Oxycontin, Dilantin, Disulfiram, or Cisplatin regularly, any injury assessment may not be completely accurate, as sensation and pain are diminished; an injury you think is mild might be quite severe. For the same reason, client perception and sensitivity of pressure are also diminished. If you are seeing this person once, work very gently. If they are to become a regular client, ask them to schedule an appointment with you before they take their medication so you can retest and re-palpate the injured structure without the medication at full strength in their system.

Beliefs vs. Facts

Belief: Pain down the leg (sciatica) is caused by pressure on the sciatic nerve.

Fact: The sciatic nerve consists of five separate nerves wrapped together. There is rarely, if ever, pressure on all of them at once. One or possibly two nerves could be compressed by one or more injured, extruded disks. However, most cases of pain down the leg are caused by injury to structures like the sacroiliac or sacrotuberous ligaments, the hip joint, or the gluteus medius muscle, not just the sciatic nerve or its branches.

Belief: When a tendon is chronically injured, we call it tendinitis because the tendon is inflamed.

Fact: We now know there are no inflammatory cells when a tendon has been injured for an extended period of time. We now know it to be tendinosis, where the cells are deteriorating. Tendons are connective tissue structures that are primarily composed of collagen and elastin fibers, which lend the structure its strength and also a small amount of flexibility. Primarily designed to transmit a strong tensile (pulling) load from muscle directly to bone, tendons are not designed to be very flexible.

Tendinitis refers to a strain or micro-tearing of the tendon, and new studies show a symptomatic degeneration of the tendon with vascular disruption and inflammatory repair response. Conversely, tendinosis is defined as intra-tendinous degeneration due to atrophy (aging, micro-trauma, and vascular compromise). In recent research, most tendinitis complaints have been found to be lacking inflammatory cells. The main issue in these tendon disorders (referred to as tendinosis) appears to be collagen degeneration from overuse. Massage therapy, specifically deep-friction massage, is beneficial, as it stimulates the production of collagen in damaged tendon fibers, rather than only breaking up fibrous scar tissue in chronically inflamed tendons as previously thought.

Belief: Most chronic pain and injury is caused by excessive muscle tension.

Fact: I’ve given talks on muscle tension and pain, and even made it the central focus of my book Are you Tense?, yet—in time—I have come to realize that muscle tension is only one piece of the chronic pain puzzle, not the main protagonist. Generally, pain does not originate in the muscles.

Massage therapists receive in-depth training on muscles and their function. When something goes wrong in the body or a client presents with pain, it’s the first and often only place they look. A therapist might attribute the discomfort to a muscle spasm or an injury to muscle tissues. However, this is often not the case, especially with lasting chronic pain.

Muscle spasms are frequently identified as a source of pain, yet, in most cases, they are protective mechanisms and the result of an injury to a tissue other than muscles. For example, if a ligament or nerve root is injured on one side of the low back and you begin to move in a way that adds pressure to those structures, the muscles of the low back will seize and spasm, limiting movement and possible further injury to the ligament or nerve root.

The pain associated with an injury to muscle tissue often diminishes within a day or two or up to a week. Muscle strains and micro-tears might occur frequently, yet muscle tissue is also highly vascularized and heals quickly. Where there is ample circulation, there is a larger capacity and efficacy for effective healing.

When pain continues for months or years, it is typically indicative of damage to a ligament, tendon, joint, or bursa. These structures are also frequently injured, sometimes increasing with age as seen in joint damage, yet their limited blood supply makes them very slow to heal, if at all. Coupled with the slow healing process, these structures are also in high demand. Without proper treatment, but continued reuse, there can be a re-tearing of scar tissue and painful adhesions can develop between the healing fibers, contributing to ongoing chronic pain.

Knowledge about injury to each of these structures, in addition to a thorough understanding of muscle anatomy and function, is essential for effective assessment and treatment of a client’s chronic pain.

Belief: Working at the site of the pain yields the best results.

Fact: The location of a client’s pain is often misleading. In many cases, pain is referred from the source of the injury to another part of the body. A client may present with severe and inexplicable upper arm pain and insist on deep pressure directly on the most painful areas in hopes of alleviating the discomfort when the pain is actually coming from somewhere else. We might ask several questions to determine a possible cause, but we also know certain areas are capable of pain referral, including the shoulders, neck, thorax, low back, sacrum, and hip joints.

Before jumping into treatment, if it’s in your wheelhouse, do a full assessment of the area. For example, there are 12 tests for the shoulder that will usually let you know exactly what is injured, and whether it’s a tendon, a ligament, or the joint itself. If you are not well-versed in assessment protocols, remember that pain typically shows up distal to the site of injury. Focus your work on the structures proximal to the pain.

Stay Updated

It’s important to take a detailed and thorough health history when working with a new client, yet it is also necessary to periodically update those intakes for long-standing clients. This ensures you are staying current with each client’s health history and not missing important information like new signs or symptoms related to their condition or other significant health changes. In some cases, continued manual therapy and treatment could actually be detrimental to your client and require attention from their doctor, such as back pain due to a kidney stone or infection; bursitis in the shoulder or hip that would worsen with massage; or any unresolving pain that might be indicative of a more serious condition.

Be Aware of Pressure

As a general guideline, always work gently at first, increasing your pressure gradually to match the needs of each client. As you approach a new part of the body, begin again gently. It is often true that one part or one side of the body is more relaxed and can take more pressure while another part or the opposite side may handle far less. If the type of bodywork you do uses a great deal of pressure and force (like Rolfing, Hellerwork, Anatomy Trains, etc.), be especially diligent in your intake to be aware of any pain a client has in their body.

Don’t Make Assumptions

Check in frequently with your client to make sure the pressure you are using is not too much or too little. Each time you have a client change positions, make sure they are comfortable. Don’t assume all clients will speak up. Make it clear to them from your first meeting that you welcome their feedback at any time to make sure they are getting what they want and need from each of their sessions.

Keep Learning

Is your knowledge current? Can you differentiate unscientific, misleading material from researched information supported by data? New knowledge about working with cancer, pregnancy, tendon injuries, burns, physical and sexual abuse survivors, and more has emerged over the past 20 years and continues to grow. In particular, over the past 10 years, research regarding massage and cancer has suggested that certain massage therapies can benefit people affected by cancer by easing common symptoms and side effects of their medical treatments. The old myth to “never work on a person with cancer because you will spread it” has been challenged by practitioners and thinkers in cancer care and oncology massage therapy. We now have evolved techniques specifically modified for cancer care that allow us to work with people safely. It’s important to be able to differentiate between what is an old myth, belief, and/or misconception and what is current knowledge.

Seek Specialized Training

If you are interested in oncology massage, or working with pregnant clients, individuals with injuries, postsurgical scars or burns, and so forth, get the training you need to be competent. Be aware that some skills take longer to master than others, and some need follow-up supervision or mentorship. For example, skill in working through all stages of pregnancy takes about 30 hours of training; oncology massage takes a minimum of 24 hours of training; and the assessment and treatment of injuries for the complete body takes approximately 150 hours. There are always opportunities to grow your knowledge and refine your skills.

There are a wide range of trainings and courses available for work with oncology massage, pregnancy massage, fascia, surgical scarring, lymph disturbances, and more. Do your research and find a teacher or program that helps you meet your goal.

Be Humble and Refer When Necessary

When you encounter a client with a problem you are not familiar with, do you research the issue? Do you request supervision from a teacher or mentor? Do you refer the client to a therapist or practitioner who is trained and experienced in that issue? Or do you assume you can work with just about any problem? There is a saying: A little knowledge can be a dangerous thing. I have been involved in court cases where therapists have taken a four-hour class and think of themselves as experts. Becoming an expert takes a long time, often years of hands-on work alongside continuing education. Maintaining humility about what we know and what we don’t know is an important and respected quality in a responsible therapist. One useful way to check your knowledge and level of skill is to solicit regular, honest feedback from your peers, a more experienced therapist, or a teacher you respect.

Self-Care

Last, but certainly not least, take care of yourself! Your attention to your work with clients is only strengthened by the attention and care you give yourself. Take notice of how you feel within your own body, address any issues that arise, and place equal value on your own rest and recovery, as the work is physically demanding. I’ve written and taught extensively on creating solid self-care practices, and I find that implementing attainable goals allows for consistency and success. Here are four areas I focus on:

Sleep

Sleep is one of the most powerful, restorative gifts we can give our body and mind. While sleeping 6–8 hours is optimum for most people, the actual amount of time needed varies for each person. It’s more about the quality of your sleep. How do you feel upon waking? Rested or restless? Groggy or energized? Take note. Small adjustments around your bedtime routine can have a large effect. For instance, limit screen time, shift the time of your last meal to allow for proper digestion, or set aside time to stretch or unwind with relaxing music.

Exercise

There are countless studies and recommendations pointing toward the benefits of a daily exercise program. Find what works for you, your body, and your schedule. Try to include a mix of aerobic exercise along with a stretching practice. The key is finding and choosing something you actually enjoy so you can create a consistent practice. Exercise can be anything from swimming to hiking or even going for a daily walk. Aim for at least 30 minutes, and take note of what feels the best for you.

Nutrition

I studied a lot about nutrition and believe the most important and basic advice I can give is to learn how to cook. Dining out not only cuts into your budget, but oftentimes meals are prepared with lower quality or unnecessary ingredients that can leave you feeling temporarily satisfied but less nourished in the long run. Start simple and choose quality, nutrient-dense foods when creating at-home meals. As suggested by most experts, try to avoid refined sugars and limit alcohol and caffeine intake. You may start to notice you have more energy throughout the day and also more quality sleep at night.

Support

One of the most important pieces of creating and maintaining a successful self-care practice is to bolster it with a supportive network within your personal and professional life. Do you have colleagues, peers, and even mentors you can call on with challenging client issues? Do you feel confident and appreciated by the people around you? Do you feel valued at home and at work? It’s important to seek out and build support systems in our professional and personal lives that ultimately challenge us while offering us nonjudgmental spaces to share so we can grow as individuals. Again, take note of how you feel around friends and peers. Do you feel energized or depleted? Are you able to ask for help or guidance, and also actively listen and give back? Feeling like you are part of a community at large is just as nourishing as any other self-care practice.

Conclusion

Attention to client well-being safeguards your practice while promoting its growth. Diligently taking a thorough health history, implementing the above guidelines, and being aware of how to skillfully apply techniques will maximize the benefits both you and your clients get from each and every massage session. This paves the way for creating a positive therapist-client relationship rooted in safety, awareness, respect, and trust.

Note

1. Tracy Walton, “Massage Therapy Pressure Scale,” in Medical Conditions and Massage Therapy: A Decision Tree Approach (2011), www.tracywalton.com/wp-content/uploads/2015/04/Walton-Massage-Therapy-Pressure-Scale-for-WEBSITE.pdf.