Any therapist who has injured a hand or arm knows how important the thumbs are to a massage career

As a massage therapist, your hands are the tools of your trade. They are quite literally your money-makers. Any therapist who has injured a hand or arm knows how important the thumbs are to a massage career. Yet, many massage therapists who do clinical work are damaging their hands every day by overusing their thumbs.

Second metacarpal on levator scapula: Using the head of second metacarpal to push down the levator scapula and trapezius muscles helps to avoid overusing the fingers and thumb on the neck.
Second metacarpal under occiput: The head of the second metacarpal works wonderfully under the occiput in a supine position.

Let’s be clear: Every activity causes wear and tear on the body. If you do anything enough times it will cause changes in the body and potentially damage it. That said, overuse injuries of the hand are extremely prevalent in massage therapists and cause many therapists to burn out.

Tendinitis, tendonosis, osteoarthritis and trigger finger are just a few of the ways in which massage can injure the hands. Further, osteoarthritis in the interphalangeal joint, the metacarpal phalangeal joint and the carpometacarpal joint of the thumb are the most common issues caused by overuse of the thumb. Many massage therapists also develop tendinitis in the flexor and extensor muscles of the thumb.

Second proximal interphalangeal joint on foot: Working precisely on the foot with the second proximal interphalangeal joint in a prone position.
Second proximal interphalangeal joint on hand: You can use the second proximal interphalangeal joint on small areas such as the thenar eminence of the hand in place of your thumb.

We know that overusing the body is going to damage it over time—so how do you extend your career and protect your tools?

The answer: less thumbs.

The Abused Thumb

Many massage therapists—experienced and new—consider themselves a “thumb specialist.” These therapists do the bulk of their work with the thumb. Stacking the joints, a popular form of body mechanics, is great; however, even with this technique you are still putting a significant amount of pressure on the small joints of the thumb. These joints are ideal for delicate, fine movements with great sensitivity—but not for heavy, sustained pressure, day in and day out.

Second proximal interphalangeal joint on levator scapula: Working on the levator scapula muscle with the second proximal interphalangeal joint in a prone position as an alternative to the thumb.

One reason many massage therapists continue to overuse their thumbs is they feel like they have better sensitivity when using their thumbs. (This is a valid point when doing, for example, trigger- point work.)

Second proximal interphalangeal joint on levator scapula II: To avoid overusing your thumbs you can utilize the second proximal interphalangeal joint on the levator scapula muscle in a prone position.

A large part of this sensitivity is due to familiarity. If you are used to using your thumbs it will feel awkward to use other parts of the hand or arm. This will pass with practice. You can still use your thumbs; I often use them to locate a trigger point, for example, then switch to another tool for compression.

Fifth metacarpal on erector spinae: Employing the head of the fifth metacarpal to work the large erector spinae muscle group in a prone position. An effective method for cross fiber manipulation of these large muscles.

Many massage therapists who injure their thumbs repetitively end up using a thumb-saver type of tool to keep working. But can you feel more through an artificial tool or through another part of your hand?

Let’s talk alternatives. If you want to minimize the use of thumbs during massage, you need to incorporate a wide variety of other bony parts of the hand and arm. Which tool you use will be determined by the size and shape of the area of the body you are working on. Everyone is different, and the best tool is the one that fits the space the easiest and allows you to spread the work over a variety of tools.

Fifth metacarpal on glutes: A great way to apply heavy pressure when working the glutes and save your thumbs is to use the head of the fifth metacarpal.
Fifth metacarpal on glutes II: Using the head of the fifth metacarpal to work on the glutes in a prone position. A great way to apply heavy pressure without overworking the fingers and thumbs.

Proximal interphalangeal joints. The proximal interphalangeal joints of fingers two through four are a great alternative to always using the tip of your thumb. You can use the second finger’s proximal interphalangeal joint on small areas of your clients like the neck, occipital region, hands and feet.

Olecranon on flexors: Working on the flexor muscles of the forearm with the olecranon process of the ulna thus limiting the amount of thumb and finger strain.
Olecranon on flexors II: Working on the flexor muscles of the forearm with the olecranon process of the ulna to avoid overusing the hands.

 I often use all four proximal interphalangeals on both hands simultaneously to pull up the posterior neck muscles while the client is supine. On feet, I use all four proximal interphalangeal joints of one hand to strip down the sole of the foot for flexor digitorum brevis and quadratus plantaris.

For cross-fiber techniques on larger areas, like the erector spinae group, you can also use all four proximal interphalangeal joints at the same time. You can use both hands side-by-side to work a really large area at once. You can use a proximal interphalangeal joint nearly any time you would have used a thumb.

Olecranon on glutes: For heavy pressure to work the glutes or the deeper piriformis muscle the olecranon process of the ulan is king.

Metacarpal bones. The heads of the metacarpal bones are also wonderful alternatives to thumbs. Specifically, the secondand fifth ones—on the index and pinky fingers—respectively. These can be used to work a variety of areas of the body.

The head of the fifth metacarpal can be used to work large areas such as the erector spinae group and the quadratus lumborum as well as the gluteal muscles and hamstrings, while also being useful for smaller areas such as the soles of the feet and palms of the hands. You can also use it to work the teres major and minor as well as the triceps brachii.

Olecranon on traps and levator: The olecranon process can be used in the shoulder region in place of thumbs for muscles such as the trapezius and levator scapula.

There is a technique in tui na called rolling that utilizes the fifth metacarpal head and is my go-to technique for avoiding overuse of the thumbs because it works for so many areas of the body. The second metacarpal head can be used to work the neck region in a supine position, including working the suboccipitals, splenius capitis, trapezius and levator scapula muscles.

The heads of metacarpals two to four can be used together to strip longitudinally down large, long muscles like the erector spinae. I often do this bilaterally, using both hands at the same time. These heads can be used for cross-fiber manipulation or for trigger-point work.

Olecranon on traps and levator II: With a little practice you can precisely modulate pressure with the olecranon process to work tender areas such as the levator scapula and trapezius.

The key to using the metacarpal heads is to hold a relaxed fist. If the fingers are relaxed they will move out of the way so the pressure can be applied directly with the head of the metacarpal without straining the extensor digitorum muscle.

Pisaform bone. One of my favorite thumb replacements is the pisiform bone. This carpal bone is small, hard and easy to use. Anywhere there is enough room for your hand—such as the shoulder/pectoralis region, the back and thighs—is a great choice for the pisiform bone.

The trick to safely using it is to allow the whole hand and wrist to make contact while concentrating the pressure through the pisiform itself. This way, you do not injure the extensors lifting the hand off the surface but the pressure is still through this small carpal bone.

Olecranon under occiput: If the clients and your size allows, the olecranon process is even useful for working the muscles under the occiput.

The pisiform bone is wonderful for rhythmic compression on a region. You can easily focus pressure just on the pisiform or spread it out on the whole palm.

Caution should be used with this technique so pressure isn’t applied over the carpal tunnel excessively. Otherwise, you run the risk of irritating it.

Forearm and elbow. Another effective way to avoid overusing thumbs is to use the forearm and elbow, more properly the ulna and its olecranon process. Massage therapists often will use the ulna to work broad areas such as the back. The forearms work well for the lumbar region as well as the entire erector spinae group. The ulna can be utilized to work long muscle groups such as the quadriceps muscles of the thigh quite effectively.

Proximal interphalangeal joints on erector spinae: Using all 8 proximal interphalangeal joints to work a large bundle of the longissimus muscle of the erector spinae group. This cross fiber technique completely avoids compressing the thumbs while working a tight muscle.

I often treat the flexor and extensors of the forearm with my ulna. Often the olecranon process is used to work with heavier pressure, such as when working the deep six lateral rotators of the hip, including the piriformis muscle. It is also commonly used, and works well for, the upper trapezius muscle; however, consider that the olecranon process is a rather small protuberance and can be used for more detailed work such as the flexor and extensor groups of the forearm or the feet.

Proximal interphalangeal joints on foot: Dragging down the sole of the foot with the proximal interphalangeal joints of all four fingers is an effective way to work the flexor digitorum brevis and quadratus plantaris muscles without using your thumb.

Don’t be afraid to try using your elbow in unusual areas. One place the olecranon works surprisingly well is the suboccipital-and-cervical region.

Thumbs Are Sometimes Best

All of this isn’t to say you should never use your thumbs; in fact, the thumb is a wonderful tool for very precise, delicate work. I use my thumbs for bodywork on the face, and also to work the scalene muscles. There are certain techniques on the hands and feet where the thumb is ideal. I utilize my thumbs for grasping techniques on the neck and extremities.

Pisaform on hamstrings: The palm is a great tool to do compressive strokes on muscles like the hamstrings of the leg. This can be focal pressure through just the pisaform, or broad pressure through the whole palm.

The goal is simply to minimize the unnecessary use of the thumbs. If another tool works as well or better, choose the other tool. When nothing else works better, use the thumb.

Pisaform on quads: When working large powerful muscles like the quadriceps group, the pisaform is an excellent tool due to its harness and ability to apply focal pressure for working specific spasms.

I try to keep use of my thumbs to no more than 10% to 15% of a session—because the key to a long, healthy career in bodywork is protecting your money-makers.

About the author

Nate Novgrod

Nate Novgrod, MAcOM, Dipl. Ac. (NCCAOM), LAc, 4th Duan, is a licensed acupuncturist and educator. He runs Waynesville Wellness and also teaches continuing education courses for acupuncturists and massage therapists. He trained at the Oregon College of Oriental Medicine. His courses for massage therapists are approved by the National Certification Board for Therapeutic Massage & Bodywork. He has studied tai chi for more than 23 years.