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Massage Today
December, 2011, Vol. 11, Issue 12

Learning from Harm

By Keith Eric Grant, PhD, NCTMB

In 2003, Ernst and Grant separately reviewed the medical literature for reports of harm from massage therapy. Both papers were consistent with Ernst's conclusion that, "Massage is not entirely risk free.

However, serious adverse events are probably true rarities." I want to briefly point out and review four case reports added to the literature since those two reviews. First, let me add some motivating comments.

As noted by Cohen and Nelson (2011), the legal basis for the regulation of health care practices by the states is protection of the public from harms of incompetence and malfeasance. The latter is primarily a function of oversight and discipline. The first, ensuring competence within scope of practice, has elements both of training and of monitoring for capacity to practice. Here, I'm focusing on the aspect of training.

The importance of a scope of practice is to define what tasks a practitioner is expected to competently perform, in what contexts, and the presence of what co-morbidities. Looking at case reports of injuries might provide a window on flaws in the expected competencies. However, It isn't enough just to know that an injury occurred. We need to identify the nature of the risk and determine if specific changes in training and practice protocols can eliminate or reduce it.

Aksoy et al. report the case of a 38-year-old woman with complaints of persistent right shoulder pain and limited range of motion (ROM) after a single session of deep tissue massage. There were no predisposing factors or specific muscle pains prior to massage. During a deep tissue massage for purposes of relaxation, she felt pain on the left side of her neck and at the top of her left shoulder radiating toward her arm while work was being done along her neck and shoulders. The pain continued afterward, and the patient noted that her left arm felt "long and heavy" while standing. She also had difficulty lifting her arm up and reaching back. There was no numbness or tingling during or after the deep tissue massage. Subsequent diagnosis indicated injury to the spinal accessory nerve, resulting in weakness of the trapezius muscle and scapular winging. While pain resolved, two years after injury recovery of strength was only partial. While a cautionary note for deep work at the neck and shoulder, no details are given that allow technique evaluation. Any sudden pain during massage treatment follow by subsequent indications of motor impairment should be taken as a clear indication for referral.

Crump and Paluska report a case of venous thromboembolism (VTE) following vigorous deep tissue massage in a previously healthy 67-year-old man with no identifiable risk factors other than his age. The authors note that physicians are often either unaware of or fail to follow evidence-based guidelines for the prevention and treatment of VTE. In this case, there was a five-day delay between initial medical examination at an emergency room and initiation of treatment subsequent to a second exam by his primary care physician. The patient reported a history of right calf pain and swelling, which had preceded the onset of his back pain by five days. The right calf symptoms had begun the day after receiving a vigorous deep tissue massage (for nonmedical reasons), which had included the lower extremities. His calf symptoms had gradually improved over the next five days, at which time he developed the right upper thoracic pain that had prompted his initial visit to the emergency department. The reporting physicians' conclusions are simply cautionary.

This case report suggests that nonpenetrating trauma to the legs, such as vigorous massage, is a potential risk factor that might be unrecognized and underreported. This report should not necessarily deter individuals without any known risk factors for VTE from receiving massage therapy. Additional research is needed to clarify the risks associated with nonpenetrating trauma to the legs, especially in older adults and other susceptible groups.

Wu and Wang report on a 40 year-old woman with injury to the posterior interosseous nerve (PIN) following a local friction massage for tennis elbow (lateral tendinosis). A detailed review of history and physical examination did not reveal any other possible etiology other than the friction massage. The technique anomaly in this case appears to be extension of the friction massage to more than 4 cm below the epicondyle. The authors note that such extension exposes the PIN to risk of damage via compression in its path through the supinator muscle. They recommend that friction massage not extend more than 4 cm below the epicondyle.

Lee et al. report on a cervical cord injury after massage in a 47 year-old male. In this case, the massage was for relaxation. He lied supine without a pillow under his neck, and passive range-of-motion exercise was applied as warm-up movements for his arms. The operator then applied oil on his body, followed by gliding and compression over his anterior thorax and bilateral neck. Suddenly, he felt acute weakness of all four limbs. The weakness remained even though the massage was stopped immediately. He needed moderate to maximal assistance to stand and walk.

There is nothing particularly striking in the description of the techniques themselves. The authors note that the mechanism of injury is not clear. However, the client had a history of cervical spine degenerative disease and had also experienced far more limited muscle weakness following a previous massage. The report underscores the need for taking a history and in obtaining medical clearance for massage where there are factors predisposing toward serious injury.


  1. Aksoy IA, Schrader SL, Ali MS, Borovansky JA, and Ross MA. Spinal Accessory Neuropathy Associated With Deep Tissue Massage: A Case Report. Arch Phys Med & Rehab. 2009;90(11):1969-1972. DOI: 10.1016/j.apmr.2009.06.015.
  2. Cohen MH and Nelson H. Licensure of Complementary and Alternative Practitioners. Virtual Mentor. 2011;13(6):374-378.
  3. Crump C, and Paluska SA. Venous Thromboembolism Following Vigorous Deep Tissue Massage. Phys Sportsmed. 2010;38(4):136-139. DOI: 10.3810/psm.2010.12.1836.
  4. Ernst E. The safety of massage therapy. Rheumatology (Oxford). 2003;42(9):1101–1106.
  5. Grant KE. Massage safety—injuries reported in Medline relating to the practice of therapeutic massage—1965–2003. J Bodywork Mov Ther. 2003;7(4):207–212.  DOI: 10.1016/S1360-8592(03)00043-3.
  6. Lee T-H, Chiu J-W, Chan R-C. Cervical Cord Injury After Massage. Amer J Phys Med & Rehab. 2011;90(10):856-859. DOI: 10.1097/PHM.0b013e318228c27c.
  7. Wu Y-Y, Hsu, W-C, Wang H-C. Posterior Interosseous Nerve Palsy as a Complication of Friction Massage in Tennis Elbow. Amer J Phys Med & Rehab. 2010;89(8):668-671. DOI: 10.1097/PHM.0b013e3181c567af.

Click here for previous articles by Keith Eric Grant, PhD, NCTMB.


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