Medical terminology can sometimes cause massage therapists to feel less sure about our ability to provide valuable treatment to clients—and there are plenty of medical diagnoses that are contraindicated for medical massage. Osteoarthritis is not one of those. Massage for osteoarthritis can really help clients feel better and manage their symptoms.
May is National Arthritis Month, a time to draw attention to this common condition. By letting clients and potential clients know of the benefits of massage for osteoarthritis, you can promote your educated touch.
Arthritis broadly means inflammation of one or more joints in the body. According to the Centers for Disease Control and Prevention, one in four adult Americans has some form of doctor-diagnosed arthritis. Given that it is affecting a vast section of the population, I highly recommend getting comfortable providing treatment to these clients.
There are many different types of arthritis, which can each have different causes. Age is a major factor, with instances of arthritis noticeably increasing the older you get. In addition, poor-to-fair diet, genetics and a low fitness level correlate to higher instances of arthritis. Women are statistically slightly more likely to have arthritis than are men.
Other Types of Arthritis
Some types of arthritis respond very well to massage therapy in most clients. Other types of arthritis don’t respond well at all to massage in most clients. Knowing which is which and helping your clients distinguish whether or not working with you can help them is an important part of your intake process.
Rheumatoid arthritis is a systemic autoimmune condition where the body’s immune system attacks its own joint tissues. While some rheumatoid arthritis sufferers swear by massage to help manage their condition, the majority find it actually exacerbates their symptoms and doesn’t have any noticeable improvement after the flare-up.
In general, if a client comes in knowing they have rheumatoid arthritis, I try to warn them of this and ask them to be truthful with themselves and me about the outcome of the session afterward. If they feel worse, I refer them to an acupuncturist, as in my experience acupuncture seems to get much better results. If they are in the minority who does respond well to massage, then we continue sessions.
Psoriatic arthritis, of which I am a sufferer, is also an autoimmune condition, but contrary to rheumatoid arthritis, tends to respond very well to massage therapy. If it didn’t, I probably wouldn’t have become a massage therapist in the first place, as I was a regular massage client long before I decided to go to massage school.
The most common form of arthritis is osteoarthritis, with 10% and 13% of American men and women living with this condition, respectively, according to the National Institutes of Health. Unlike the other types of arthritis, it is not an autoimmune condition. Osteoarthritis is generally caused by wear and tear, as well as age-related loss of calcium due to muscle atrophy.
Osteoarthritis responds very well to medical massage therapy, most especially in situations where wear and tear are the cause. The focus of the rest of this article will be on how massage therapy can help osteoarthritis specifically, although the techniques described work well with most other types of systemic arthritis in those clients who respond well to massage.
Conditions & Symptoms of Osteoarthritis
Unlike the autoimmune forms of arthritis, which attack all joint tissues, osteoarthritis occurs over time as the cartilage protecting bones breaks down. It is caused mainly by wear and tear. As such, it tends to show up in joints that receive the most impact—knees, hips and spine—as well as our hands. (I’m looking at you, massage therapists.)
By far, being overweight and inactive are the most common reasons osteoarthritis shows up as clients age. In addition, any activities that increase impact on the joints can increase the likelihood of occurrence. These activities will also increase the likelihood of it showing up earlier in life. Sports involving moderate to high impact such as football, soccer, running and skiing make it even more probable.
Unfortunately, cartilage is a tissue our bodies make once and expect to use for the rest of our lives. Once it’s been worn down or destroyed, your body can’t replace it, despite what the ads for many supplements claim. There are newer medical technologies, such as injectable hyaluronic acid (the fluid that exists inside joint capsules) that are starting to be able to act as a replacement for lost cartilage. Currently those treatments tend to provide relief for four to six months before breaking down and so are not yet close to a long-term solution. For the foreseeable future, our best bet is preventing cartilage breakdown in the first place.
Once it starts wearing down, cartilage loss can lead to a number of symptoms, such as pain, stiffness, swelling and loss of flexibility. Longer-term symptoms can include grating, crackling or popping sensations in the joint, as well as bone spurs.
Pain and other symptoms are usually intermittent at first, such as showing up in the knees only when walking downhill or down stairs. Untreated, symptoms will generally worsen over time and lead to constant achy pain with some activities resulting in sharp pain. Eventually the joint may degenerate to such a degree that a joint replacement surgery to the knee or hip or a fusion surgery to a pair or more of the vertebrae is the current best option for a client.
Massage for Osteoarthritis
The root cause of osteoarthritis symptoms can’t be fixed currently; however, symptoms can be often managed and usually improved without surgery or medication with a combination of physical therapy and massage therapy.
Physical therapy is helpful to strengthen the joint and provide stability to the surrounding muscles so they can better absorb impact and force without further degrading the cartilage and bone. Massage therapy can help decompress the joint, open up the surrounding musculature, and restore range of motion.
In addition, massage therapy can help a client to better balance load-bearing activities throughout the body to help take pressure off the arthritic joints. This is especially important if the wear and tear is being exacerbated by a misalignment, such as an externally rotated knee.
Such decompression techniques as stretching and traction help create space in the joint, which will decrease further wear and tear. In addition, local work on all of the muscles surrounding the joint can help restore range of motion and flexibility.
Joint decompression takes time and patience and often works best without trying to immediately stretch the muscles to the end range of motion. You will get better results if you allow the muscles themselves to relax and stop trying to protect the ligaments and joint capsules. Going slowly and easily will also prevent the muscle stretch reflex from triggering and firing to protect again.
It is also easy to get stuck looking exclusively at the joints that are symptomatic, so remember the joint exists in a whole load-bearing system. For example, wear and tear in a knee is often exacerbated by misalignments caused by other factors. Some common factors are a previously sprained ankle, plantar fasciitis or even seemingly small issues such as bunions.
In a client with knee arthritis, it is very common for the ankle to no longer hinge correctly from an older sprain. Proper ankle hinging means the foot is able to hinge noticeably and directly toward the knee and hip without needing to evert or invert. If this is restricted, the knee will externally rotate to compensate, causing wear and tear of the medial meniscus and knee cartilage over time.
Ankle Work to Free the Knee
Improving ankle mobility and stability will allow the knee to relax into a better, more neutral position, balancing pressure through the whole structure and decreasing the unbalanced wear and tear:
1. Traction one leg into a gentle stretch, holding the foot and ankle so the foot points straight up, and so the ankle lines up with the knee and hip on what would be a “plumb” line if they were standing.
2. Make sure the plane of the foot toe bed is perpendicular to this plumb line.
3. Try to dorsiflex the ankle toward the knee.
4. Look at how this affects the knee and hip. On clients who have had previous ankle sprains, this hinge isn’t fully available and the hip will internally rotate with the knee externally rotating and falling inward toward the other knee to compensate. Imagine this happens for the client with each step to some degree, and over time it will grind away at the cartilage and meniscuses.
5. To help balance the knee, do some local ankle work to free up the calcaneus/tallus joint and the ankle joint. Your goal should be to re-test and hopefully be able to better hinge the ankle without the knee or hip needing to move. The more you can help facilitate this proper ankle movement, the less work the knee muscles have to do to stabilize the knee, which in turn lessens wear and tear on the joint.
The above test can similarly help for hip issues as well. All three joints—ankle, knee and hip—work in a system when walking or running. Restriction or lack of stability in any of the three will affect the others. In addition, improper loading of the joints in one or both legs will result in more impact or compensatory pressure on the lumbar spine in particular and potentially the rest of the spine.
Working to get the entire functional chain to balance load in gravity (i.e. more properly aligned) will help distribute force throughout and decrease pressure on the arthritic and symptomatic joints. This will have the short-term benefit of lessening and relieving symptoms and the long-term benefit of slowing the decline of the joints as the client ages.
Management of Symptoms Off-Table
One of the counterintuitive reasons my private practice has been so successful over the last 15 years is I’m not shy about referring my clients to other practitioners and suggesting practices for them to do at home or work.
I always tell clients I want our sessions to have the maximum possible impact so they can improve with the least number of visits needed and hopefully get to a point where they no longer feel they really need my services beyond a regular maintenance massage every eight to 12 weeks.
This involves educating myself so I can educate them about ways, such as stretches and hydrotherapy, they can help prevent relapses. I also try out and get to know other practices that can help them, such as Pilates and tai chi, and being able to recommend places they can go to learn those techniques.
It also means keeping up to date on the latest medical interventions such as hip resurfacing or hyaluronic acid injections and being able to support a client in deciding with their surgeon that it’s time to take these steps if nonsurgical treatments are no longer relieving symptoms.
For those of you in private practice, having a diverse referral network is a wonderful boost to your own practice, and I would encourage you to try out as many modalities and fitness practices as you can that are in alignment with how your own body works and responds.
For arthritis clients, of both the osteoarthritis and systemic arthritis varieties, a “move it or lose it” approach is the best for their long-term health. I further suggest defining that phrase to mean a smart and balanced approach with some light-to-medium strength training (without needing to get jacked) and some balance training, as well as some stretching and self-care practices.
Clients who both feel better after working with you and feel like they can gain tools to better manage their symptoms themselves without you will become your most avid fans—and they will send everyone they know your way.
You’ll become shocked at how often you’ll hear the story from a new client that they were just having dinner with so-and-so and started complaining about their low back pain. Then so-and-so whips out your business card (that apparently they carry at all times) and tells them, “you have got to go see my massage therapist … ”
About the Author
David Weintraub, LMT, owns Bodyworks DW Advanced Massage Therapy, a pair of medical massage studios in New York, New York. Bodyworks DW is a National Certification Board for Therapeutic Massage & Bodywork-Approved CE Provider in New York and nationally. His small-group live, webinar and on-demand CE courses offer training on advanced techniques, with a focus on improving assessment and treatment design to get better results with a wide range of clients.