This is the final installment in our series on occupational injuries and designing effective treatment strategies to address them. It seems only fitting that we wrap this series up with a discussion of injury conditions that plague massage therapists.
One of the key reasons people leave the massage profession is physical injury. People enter this field with excitement and enthusiasm, only to realize that it is a physically demanding occupation. In 2006, authors Lauriann Greene and Richard Goggins reported on a survey conducted by ABMP regarding injuries to massage therapists. The survey identified the problematic body regions and injuries most reported by massage therapists. In this final installment, we’ll take a look at some of these conditions and identify key strategies to address both conditioning factors and injury reduction.
Thumb Pain
One of the most common pain complaints from massage therapists is pain in the thumbs. Numerous massage techniques are designed to take advantage of the opposable action and large range of motion of the thumb. It is a tool ideally suited for applying deep pressure, as well as performing sweeping and gliding movements. The downside is that the anatomical architecture of the thumb is not cut out for the types of stresses massage techniques accumulate.
The most common thumb complaints arise from using the thumb for static compression or deep gliding techniques that use significant pressure. When the thumb is used in proper alignment for these types of techniques, the detrimental impact of compression loading is reduced (Image 1). However, even then, accumulated stress can lead to joint damage. Because the thumb is not a weight-bearing joint, it is not ideally suited for the high levels of compression that occur in these techniques.
While long-term compression forces can be damaging to the thumb in almost any situation, the majority of thumb injuries occur from improper mechanics. When deep pressure is applied with the thumbs in a misaligned position, the supporting ligaments, joint capsules, and tendons must absorb the load. The pressure of the stroke is thus both less effective and more damaging for the thumb joint (Image 2).
The thumb is highly effective at delivering deep, specific pressure, and it is tempting to continue using it for this purpose despite the likelihood of eventual injury. Unfortunately, a debilitating thumb injury can be career ending. The most effective way to reduce thumb injury is to use an alternative small contact surface. Fingertips can be used for certain techniques, but the elbows or knuckles are also useful.
Pressure tools are another option, and there are many on the market. Find one that fits well with your hand and your working style. I have several: some I have had made specifically for my own use, and others, like the Shemala Finger Press Massager (Image 3), seem to best replicate the feel and flexibility of a natural thumb or finger.
I operate the pressure tool with one hand and place a fingertip or thumb of the other hand next to the pressure tool contact surface, which allows me to palpate the tissue’s response with a fingertip or thumb pad while delivering effective treatment pressure. Accurate placement of the tool, appropriate pressure, and attention to tissue/client response is critical for preventing client injury.
Forearm/Wrist Injury
Massage treatment involves significant upper-extremity muscular effort, and it is no surprise that practitioners experience overuse injuries of the forearm and wrist. The most common conditions involve chronic muscle-tendon overload leading to tendinosis. This condition is most common in the wrist flexor and extensor tendons at their proximal attachment sites.
Tendinosis involves collagen degeneration from extensive and repetitive overload on the tendon. Unlike tendinitis, which is actually quite rare, tendinosis is not an inflammatory condition and does not respond to traditional anti-inflammatory overuse treatment strategies. It does, however, respond quite well to massage treatment.
The most effective way to avoid developing tendinosis is through conditioning. This does not necessarily mean you have to regularly do high-intensity weight training. However, putting a regular degree of appropriately designed biomechanical stress on a muscle-tendon unit makes it stronger and more resistant to the degenerative changes that lead to tendinosis.
Simple conditioning exercises for the wrist flexor and extensor muscles can be performed by taking a broom in one hand and drawing figure-eight designs in the air. The level of resistance for the muscles is determined by how close the hand is to the end of the broom. Experiment with placing your hand in different locations along the broom handle to determine a good level of resistance for doing about 10 repetitions of this movement at a time.
If you have already developed tendinosis, massage performed on those affected tendons will be very helpful. Pressure and movement applied consistently to the tendon help encourage fibroblast proliferation, which then encourages a faster recovery from the collagen degeneration. The more frequently this treatment is applied, the faster the healing process and the greater likelihood of getting back to good functional activity.
The challenge in treating yourself is that you have to engage the affected muscles once again to apply the treatment. However, there are some alternative methods to apply massage to your own forearms without extensively using your wrists. Pressure tools can be effectively applied to the forearms as well. The backside of a hand or a rolling pin (or a foam roller or other rolling device) can also be used as a massage tool to work the opposite extremity’s flexor and extensor muscles without muscle overuse.
Another common injury that occurs from chronic overuse of the wrist flexor and extensor tendons and those of the thumb and fingers is tenosynovitis. This is a condition involving inflammation or irritation between a tendon and its surrounding synovial sheath. It frequently develops along the radial aspect of the wrist in a condition called De Quervain’s tenosynovitis (Image 4), but it can also develop in the extensor or flexor tendons on the dorsal or palmar side of the wrist. Tenosynovitis of the flexor tendons as they travel through the carpal tunnel is a common cause of the nerve compression in carpal-tunnel syndrome.
The inflammation and irritation of tenosynovitis develops as a result of chronic overload on the tendons. It is most effectively addressed by reducing the overload demand on the wrist flexor and extensor muscle-tendon units. Deep stripping techniques applied specifically to the affected tendons can help reduce chronic overload in the muscle-tendon unit. Even more effective are active engagement techniques where a deep stripping method is performed as the muscle is elongating, while a stripping technique with additional resistance is simultaneously applied (Image 5). The additional resistance increases density in the muscle and helps improve the penetrating effect of the stripping technique.
It is also helpful to apply deep friction directly to the affected tendon because tenosynovitis frequently involves fibrous adhesion between a tendon and its surrounding synovial sheath. Friction techniques applied to the affected tendon are likely to be painful, but they will be helpful in resolving the issue. After friction techniques have been applied, it is beneficial to encourage freedom of movement between a tendon and the surrounding synovial sheath, using movements that put the tendon through its full range of motion.
Massage therapists also routinely sustain nerve-compression pathologies in the forearm and wrist region. The most common locations of nerve entrapments involve compression of the median nerve in the carpal tunnel or between the two heads of the pronator teres muscle. Compression of the ulnar nerve is common in the cubital tunnel of the elbow or Guyon’s tunnel (also called Guyon’s canal) in the wrist.
The most effective way to address any nerve-compression pathology is to reduce compression on the affected nerve, which often results from tightness or binding by soft tissues such as muscles or tendons. Consequently, it is very important to reduce hypertonicity in these muscles so that appropriate nerve function can return, along with a decrease in pain. We have addressed these common upper-extremity nerve-compression problems in other articles in this series, so I recommend looking at those articles to examine nerve-compression pathologies in greater detail. Regular self-care should include stretching and relaxation exercises, as well as protocols that relieve chronic tension in these regions.
Neck and Back Pain
Another common complaint is neck and upper-back pain. These two are closely related, and a look at the biomechanics of massage delivery positions shows why these conditions are so frequent.
One of the key biomechanical challenges facing massage therapists is one that we investigated early in this series as a chronic complaint in the dental profession (“Brushing Up on Dental Worker Care,” March/April 2012, page 106). Like dental professionals, massage therapists usually look down and bend over to work on their clients. Long periods with the head in a forward-flexed position mean that the posterior cervical muscles must constantly fight gravity as they attempt to pull the head back and resist gravity’s downward force (Image 6).
Isometric contractions of the back and neck are primarily performed by the longitudinal muscles running the length of the spine: the erector spinae group, multifidi, and semispinalis muscles. Due to the extensive fascial connections and continuity of these muscles throughout the entire spine, biomechanical stress from forward head posture is not limited to just the cervical muscles; it is transmitted down the length of the spine, leading to low-back pain as well.
Similarly, bending forward too often during a session puts a significant overload on the lumbar musculature. As the torso moves into the forward-flexed position, the upper thoracic and cranial regions come forward and the entire torso must fight the pull of gravity.
I can’t overemphasize how frequently this postural challenge plays a role in chronic-pain complaints for massage therapists. And unfortunately, so much of it goes back to poor body mechanics. As a continuing education provider, I work with practitioners who are fresh out of school, as well as many who have years of experience. One constant I see is chronically poor patterns of body mechanics that were learned, reinforced through practice, and never corrected.
Many practitioners lament their back or neck pain, and possibly even seek the help of other massage therapists. However, this is another case where the pain will likely recur quickly if the underlying biomechanical dysfunction is not changed.
Postural change is one of the most challenging aspects of rehabilitation because what is customary feels natural, and adopting a new, corrected posture feels awkward and unusual. It is also important to know when you are adopting good postural alignment in your work because you may feel like you are upright and aligned when in reality you are not.
One of the most effective ways to get a sense of your own postural alignment and how it might contribute to back and neck pain is to videotape yourself doing massage. It’s important you don’t try to make corrections during the videotaped session, but instead proceed as usual. Afterward, look at your positioning and note where the particular challenges might be with the techniques you employ. It is likely you will be surprised to see many instances of poor mechanics when you thought you were in good alignment.
The importance of appropriate body mechanics can’t be overstated. They can fundamentally change the way you feel about your work, and can make you a significantly better practitioner. I have found my early tai chi and kung fu training highly beneficial to how I work. You do not need to become a martial artist, but practices that teach good posture and mechanics—like dance, martial arts, tai chi, and yoga—are particularly useful for building your core and correcting poor posture.
In summary, any physically demanding occupation requires conditioning. Not caring for yourself is, in the end, not caring for your clients. Your dedication to your own care is one of the most important investments in your career that you will ever make.
Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe’s next free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com.
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