Takeaway: Using a variety of tools can create complexity in your work and can help prevent injury.

Massage therapists, both rookie and veteran alike, tend to struggle with an age-old pattern: We limit ourselves to primarily using our palms, thumbs, and fingers. Too often we forgo (or at least underutilize) other anatomical tools at our disposal.  

Any artist will likely tell you it takes a collection of tools and supplies to create a masterpiece. For example, if you are painting a picture, you’ll have a brush for covering large areas quickly, a brush for smaller areas and fine details, a brush for creating crisp lines, and a brush for smoothing or spreading color. Perhaps it is possible to use one universally adaptable brush to accomplish most or all of these tasks, but the final product probably won’t possess the same level of complexity.

The same can be said for anatomical tools in massage. In addition to palms, thumbs, and fingers, our fists, knuckles, forearms, and elbows are essential supplies in our creative toolkit that provide just the right stroke to meet the intended outcome.

Let’s consider the benefits of variety, then look deeper into a few anatomical tools, including how and when to use each option.

The Benefit of Variety 

One benefit of variety is avoiding injury. Just as the bristles of a brush would fray if you exclusively used that brush to paint, using the same anatomical tools repeatedly will eventually cause them (most commonly the joint component) to be compromised. Worn-out joints means your workday suddenly becomes a painful struggle instead of a joyful act of creating change.

Another benefit to using a variety of tools is that it creates complexity in your work. A forearm creates a different sensation than the palm of the hand. An elbow feels different than a thumb or a knuckle. Some tools are best for broad, dense areas, and some are better for fine-tuned details.  

Even within those categories of broad and specific, there is variety. Applying the specific approach of direct, sustained compression on an ischemic trigger point is different than using a specific frictional or shearing force on an area of adhesion. Not only does each one feel distinct, but the purpose and outcome of each is also distinct.  

Similarly, using a tool that provides detail in an area where a broad stroke would be more effective is faulty. I have experienced thumbs being used to perform a long gliding stroke up my hamstrings and it neither felt good nor supported appropriate tissue release. 

Knowing the uses and benefits of each stroke and discerning which anatomical tools are best to employ to meet intended aims are skills that are wise to cultivate.

Note: While we are currently only discussing variety in the context of anatomical tools, keep in mind that the same can be said for using a variety of lubricants, bolsters, and techniques.

A Basic Tool Tutorial

Here we will focus on four tools: soft fists, knuckles, forearms, and elbows.

Soft Fist

Body Mechanics: The region of the posterior fingers between the metacarpophalangeal joints and proximal interphalangeal joints of all four fingers will be contacting the client’s skin. Fingers will be held together while the overall hand will be relaxed. While you can use a tight or closed fist, it causes tension and strain on the muscles of your forearm. It is best to use a soft fist so these areas are less likely to get stressed and injured.

Keep your arm straight (but avoid locking the elbow joint) and your scapula retracted and drawn inferiorly so you can set yourself up to initiate pressure from your feet, legs, and core rather than from your
arm or shoulder muscles.

Primary Benefit: A soft fist is a great alternative to using the palm of the hand because the wrist joint is more likely to be kept in a neutral, aligned position.

Application: A soft fist is best for applying gliding strokes over broad surfaces and dense musculature. It’s a medium-size tool that can be used to access more surface area than the elbow but less surface area than the forearm. It is commonly used on clients’ forearms, the erector spinae group, and on individual hamstring or quadriceps muscles.  

Avoid using soft fists in bony areas, such as around the ankle joints, where there is primarily rope-like connective tissue instead of dense muscle tissue.

Knuckles

Body Mechanics: Applying massage with one or more knuckles involves making contact via flexed proximal interphalangeal joints. In contrast to soft fists, holding the finger(s) closed will keep the rest of the hand and wrist stable and protected during technique application. Use the same straight-arm approach as described in the section on soft-fist body mechanics.

Primary Benefit: Knuckles are a great alternative to thumbs. You can get the same specific and deep pressure, but with far less strain on the joints of the hand and wrist.

Application: Use a knuckle for sustained, direct-pressure techniques, such as those used to release trigger points. Additionally, you can use a knuckle to provide short, deep friction strokes to adhered tendons and ligaments.  

You can also use all four knuckles together to provide shearing strokes along the length of longer muscles that have adhered to the tissue below them. For example, you can use knuckles together along the anterior portion of the upper trapezius, the lateral portion of the lower trapezius, between the triceps and biceps, and the lateral and medial portions of the gastrocnemius and soleus muscles.  

Knuckles are small tools that can be used for both small and medium-size areas, depending on the purpose of the stroke. It is essential to be careful of pressure, though. A knuckle is a very hard, pointed tool that can be painful when applied too deeply. It is a much harder surface than a thumb, so use caution and communicate openly with your client.

Forearms

Body Mechanics: Using the forearm involves contacting the client’s body with the medial or posterior arm between the elbow and wrist joints. Do not try to use the anterior forearm, as it will inevitably cause misalignment (medial rotation) in your shoulder joint.  

Pronating one’s forearm allows use of the softer part of the forearm, while slightly supinating allows use of the harder, ulnar side of the forearm.  

Your elbow will be flexed and your stance will be lower so your body is closer to the client. Your scapula will once again be retracted and positioned inferiorly so that power and pressure can generate from the feet, legs, and core. In addition, keep length and lift in the cervical vertebrae. Often, when we lower our overall stance, there is a tendency to drop the head.

Primary Benefit: Forearm use in lieu of palms reduces stress on the wrists. As long as the scapula is correctly positioned, stress on the shoulder joint is limited. Plus, it is easier to apply deeper pressure.

Application: A forearm is great for gliding strokes over broad surfaces and dense musculature. It is a large tool that can be used at superficial or medium pressures. Use the ulnar side for more pressure and a harder feel for the client, or the posterior side for a softer feel for the client. Use on large back muscles, gluteals, hamstrings, and quadriceps. A small section of the forearm can be used strategically on a client’s forearm or calf muscles.

Elbows

Body Mechanics: Your body position during elbow use is the same as the forearm, except the elbow is flexed more deeply.  

Primary Benefit: Similar to using a knuckle, the elbow is a great alternative to thumbs. You can get the same specific and deep pressure, but with far less strain on the joints of the hand and wrist.

Application: Also similar to a knuckle, the elbow is excellent for direct, sustained pressure and shearing strokes. Think of an elbow as one step broader than a knuckle. While it is still pointed, it is slightly larger and covers more surface area. When a knuckle is too pointy, an elbow is a good alternative.  

Be aware, though, that more power backs the elbow than the knuckle because of its proximity to your body (especially your core). Again, be sure to keep client communication at the forefront.

Diversify Your “Craft” Box

While use of palms, thumbs, and fingers is inevitable, it is best to save them for strokes that can only be applied with anterior hands, such as squeezing, kneading, and percussion/tapotement. 

Additionally, the use of knees and feet is a great option; however, it is requisite to obtain proper training through continuing education on use of these anatomical tools to avoid misuse and miscommunication, which could result in injury to the client. 

Diversify your repertoire so that you ensure the outcome (or masterpiece!) you are creating is done with precision and purpose.