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Soft tissue rehabilitation is a mainstay of massage therapy in orthopedic settings.
By Maureen Salamon, November 6, 2018
With more than 300 individual joints in the human body, pain and dysfunction in the tissues and muscles surrounding those joints is a common problem. But whether due to injuries, overuse or other types of trauma, soft tissue rehabilitation is a mainstay of massage therapy in orthopedic settings and a place for massage therapists to shine.
While athletes suffer a high number of orthopedic injuries, anyone can be affected. According to 2015 research in the Journal of Physiotherapy,1 musculoskeletal disorders—especially of the shoulders and knees—are the fourth-greatest health burden globally, affecting between 20 and 50 percent of the population.
By alleviating pain and tension while restoring alignment and range of motion to joints, massage therapy’s versatility enables its use before or after orthopedic surgery or as stand-alone treatment. Indeed, massage can even avert or delay the need for surgical intervention, experts say.
“More than ever, people are willing to try massage therapy first before running to the doctor for orthopedic problems,” says Traci Aguilar, a massage therapist based in Casper, Wyoming. “They want to get the problem worked out first before they get shots or medication, and probably the vast majority of them find relief.”
“Surgery helps fix a specific problem, but it does not address the overall twisting and torqueing a person does to their body while compensating for their injury,” notes Michael Ames, a massage therapist based in Orlando, Florida. “Compensatory pain is the slippery slope of simple injuries. Massage helps prevent problems.”
Mounting studies support massage’s advantages in this realm, with even brief sessions of 20 to 45 minutes on postoperative orthopedic patients shown to be beneficial. In 2015 research in the journal Orthopaedic Nursing,2 patient satisfaction with pain management was significantly higher after receiving a combination of massage and pain medication than with medication alone.
A major 2015 review of 26 studies involving more than 2,500 participants published in the Journal of Physiotherapy3 compared massage therapy’s impact on pain and function among those with a variety of musculoskeletal problems to no treatment. Massage therapy as a stand-alone treatment reduced pain and improved function in the short-term in those with shoulder pain and knee osteoarthritis when compared with no treatment.
For many orthopedic conditions, experts say, massage often fills a void left by other clinicians. Rolando Lopez, PA-C, a physician assistant at The Orthopaedic & Sports Medicine Center in Trumbull, Connecticut, said the majority of patients he sees experience muscle spasms related to their injury or disorder.
“Massage therapists can release the tension causing these spasms,” he says. “I can give them medicine for their pain, but it’s just a band-aid.” Michele Naumann Carlstrom, a massage therapist at the Hospital for Special Surgery in New York City, which specializes in orthopedic surgery, complements efforts by physicians and physical therapists also on staff.
“Anytime colleagues have someone with soft tissue restriction, they will refer to me because you can’t gain strength without motion,” she says. “I help them gain mobility and range of motion in the joint so [others] can do their work in physical therapy and performance to keep the area working efficiently. It’s a great partnership.”
Whether administered before or after orthopedic surgery—or at both points—massage offers specific benefits to clients and even the surgeons operating on them.
“Pre-surgery, massage helps muscles to loosen up and relax, making it easier for muscles to stretch if they’re pulled away during surgery,” says Angela Candelora, a massage therapist and medical assistant at The Orthopaedic & Sports Medicine Center in Connecticut.
Ames points out that a few weeks after surgery is “often at the sweet spot of healing” for massage to add its unique value. “That’s when scar tissue is forming, but not yet unmoldable,” he says. “Techniques begin with helping the client regain mobility and reducing adhesions from the superficial to deep layers.”
As with every type of massage, a thorough pre-treatment assessment of the client is key in orthopedic pathologies. “Postural evaluations are a large part of those assessments, as well as passive and active range-of-motion testing and active resistance testing,” Ames says.
Following are several common orthopedic problems treated by massage therapists, as well as research about how massage can help and tips on techniques.
Hip pain can arise from a wide array of disorders and injuries, including arthritis, bursitis, tendinitis, strains and sprains. Pain in the low back or gluteal area can feed into hip problems and is often caused by pelvic imbalances, experts say. Alaska-based massage therapist David Edwards-Smith often sees acetabular impingement cases, where muscle(s) deep in the hip do not center the joint properly.
2011 research in the International Journal of Therapeutic Massage and Bodywork4 examined the effects of massage on pain, stiffness and fatigue in a patient with ankylosing spondylitis (AS). This condition often affects the spine, but it can also produce pain and stiffness in the hip or other areas, even eroding the hip to the point of requiring joint replacement. Massage therapy improved both the intensity and duration of stiffness as well as helping pain, fatigue, and forward and lateral inflexion in AS.
Helpful techniques include pinning and stretching the piriformis, glutes and hamstrings; psoas work; and stretching and lengthening the quadratus lumborum, Aguilar says. Candelora uses ice cups with stretching and deep tissue massage in the hip region, warming the area afterward. “It keeps inflammation down from the massage itself,” she notes.
Joining total knee replacement as a prevalent knee procedure is arthroscopic knee surgery, aiming to repair ligaments and other structures to increase stability. Knee pain can also arise from meniscus injuries; synovial plica syndrome, which produces a dull ache medial to the patella; patellar tendinosis; and patellofemoral pain syndrome, a group of symptoms related to anterior knee pain. Ames often treats clients with lateral knee pain and quadratus tendon attachment pain, which is typically linked with an imbalance in the hips, hamstrings and quad muscle groups.
The effects of massage therapy on pain, swelling and range of motion after total knee replacement surgery was examined in 2015 research published in the Journal of Physical Therapy Science.5 The study found that massage is a comparable alternative to physical therapy to manage knee edema early in postoperative recovery. “With joint replacements, the soft tissue around the joint has a lot of adjusting to do,” Carlstrom explains. “A new joint is put in and the tissue has to relearn how to work properly.”
Patellar problems may be helped by a pin-and-stretch technique in conjunction with deep tissue massage on the quadriceps muscles. Aguilar also advises checking for trigger points in the gastrocnemius and soleus and massaging the patellar tendon, quads and muscle attachments along the IT band. Candelora advises caution in stretching the tissues around the knee “because you have to make sure the knee is in a proper plane to not cause increased pain or inflammation.”
“In runners, I see a lot of knee problems that are caused by a tight IT band,” Aguilar says. “Releasing the glutes, quads and hamstrings helps.”
Perhaps the best-known shoulder problem is frozen shoulder, medically known as adhesive capsulitis, which involves adhesions and inflammation in the shoulder capsule in the socket. Others include bursitis, rotator cuff tears, shoulder impingements and calcific tendinitis. “I see a lot of problems stemming from bad posture,” Candelora says. “In a world where we are always reaching in front of us, our pectoral muscles are always tight, causing everyone to lean over and hunch.”
The role of massage therapy in treating shoulder pain was highlighted in 2017 research published in the Journal of Physical Therapy Science.6 Reviewing 15 prior studies involving 635 participants, researchers found that massage therapy significantly reduced shoulder pain in the shortand long-term.
Another 2017 study in the same journal7 examined massage’s impact on shoulder range of motion. Based on seven studies with 237 participants, the review indicated massage markedly improved range of motion in the joint, especially flexion and abduction.
For frozen shoulder, massage the trigger points in the subscapularis and teres minor, Aguilar recommends. Pin-and-stretch techniques in the pecs are also helpful, as is massaging the trapezius and latissimus dorsi muscles at the attachment and insertion points.
“Most massage therapists miss the areas under the armpits,” Candelora says. “Muscles there don’t get a lot of attention and end up being the root cause of shoulder and back pain.”
Perhaps the top elbow issue massage therapists treat is tennis elbow, or lateral epicondylitis, an overuse injury stemming from damage to the extensor carpi radialis brevis (ECRB) muscle. Massage therapists also report clients who are unable to externally rotate the arm at the elbow, which can be due to excessive computer use.
Deep friction massage was compared to steroid injection in patients with tennis elbow in 2018 research in the journal Hand.8 After six months, only patients in the massage group demonstrated significant improvement in all outcome measures, including pain rating, disability scores and grip strength. The research concluded it could be used for those for whom non surgical treatment for tennis elbow hadn’t worked, including cortisone injection.
Candelora performs muscle stripping along the muscle fibers leading up to the tendon itself. This helps release and elongate tight muscles. “That gets the blood flowing and helps the lymphatic drainage system to bring our body’s natural healers to that area to get it to release,” she says. Edwards-Smith adds: “You’re not so much pounding on the tendon, you’re unloading the tissues to allow it to heal.”
Overall, massage therapists can often spend more time with clients than an orthopedist can, experts say. This advantage translates into key benefits that clients can’t access anywhere else. “When someone’s in pain because of an orthopedic problem, they go to an M.D.,” Edwards- Smith says. “But the missing link is the palpation side. Massage therapists have an opportunity to really slow down and spend time with the client to feel what’s going on in the tissue. There’s insight there.”
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1. Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review, Journal of Physiotherapy, July 2015, https://www.sciencedirect.com/science/article/pii/S1836955315000582.
2. Effect of a brief massage on pain, anxiety, and satisfaction with pain management in postoperative orthopaedic patients, Orthopaedic Nursing, July/Aug 2015, https://www.ncbi.nlm.nih.gov/pubmed/26213879.
3. Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review, Journal of Physiotherapy, July 2015, https://www.sciencedirect.com/science/article/pii/S1836955315000582.
4. The effects of massage on pain, stiffness, and fatigue levels associated with ankylosing spondylitis: A Case Study, International Journal of Therapeutic Massage and Bodywork, March 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088527.
5. The effect of mechanical massage on early outcome after total knee arthroplasty: a pilot study, Journal of Physical Therapy Science, Nov 2015, https://www.ncbi.nlm.nih.gov/pubmed/26696709.
6. Effectiveness of massage therapy for shoulder pain: a systematic review and meta-analysis, Journal of Physical Therapy Science, May 2017, https://www.ncbi.nlm.nih.gov/pubmed/28603376.
7. Effectiveness of massage therapy on the range of motion of the shoulder: a systematic review and meta-analysis, Journal of Physical Therapy Science, Feb 2017, https://www.ncbi.nlm.nih.gov/pubmed/28265175.
8. Deep friction massage versus steroid injection in the treatment of lateral epicondylitis, Hand, Jan 2018, https://www.ncbi.nlm.nih.gov/pubmed/28719982.