The soft tissue injuries most common to massage therapists fall into two categories: muscle/tendon injuries and nerve impingement injuries. The primary cause of these disorders is thought to be overuse, or using a part of the body more than is considered normal or healthy.
You will often see injuries caused by overuse lumped together under the terms repetitive stress injuries (RSI??s), cumulative trauma disorders (CTD??s), or simply overuse syndromes. These injuries can be very confusing. They often overlap in causes and symptoms. You may start out with one kind of RSI, and find that it develops into another kind later on. Your symptoms may come and go, or be atypical and difficult to classify. In nerve impingement injuries, it can be difficult to determine the exact site of nerve compression, since symptoms can be felt at any point along the nerve pathway. It is also possible to have several problems at the same time, in which case you may have trouble distinguishing which problem is causing a particular symptom. Medical science, both allopathic and alternative, still does not completely understand these injuries. As a result, it is often difficult to obtain a reliable or definitive diagnosis for your symptoms. The injury descriptions provided here reflect the current level of knowledge available on the subject.
Muscle/Tendon Injuries
Overuse Syndrome
The commonly accepted definition of overuse syndrome is tissue damage caused by the cumulative effect of repetitively stressing the tissues beyond their anatomic and physiologic limits. Overuse syndrome is thought of as a chronic injury because of its gradual onset and generally long duration. There may be no definable “acute” stage to the injury, even though the symptoms may increase in severity at times. The most common injury sites in massage therapists are the thumb, the wrist, and the forearm, although overuse of the elbow and the shoulder also occur. The incidence of overuse syndrome in the general population seems to be higher in women than in men.
We generally use the term “overuse syndrome” to mean a set of symptoms and physiologic changes that do not fit into any other specific syndrome of muscle/tendon injury, like tendinitis or tenosynovitis. The symptoms and changes experienced by massage therapists most commonly fall into this category. Overuse syndrome is therefore the most common diagnosis given to injured massage therapists. The work we do involves subtle movements done repetitively for long periods (usually an hour or more at a time) without rest. Over time, little by little, tissue damage accumulates, and we begin to notice signs that something is wrong. This slow onset is one of the defining characteristics of this disorder.
The injury/reinjury cycle is the major contributing factor in overuse syndrome. You do some massage, your hands start to hurt, the tissues begin to be damaged, you ignore the pain and keep doing massage, reinjuring the tissues, causing more tissue damage, and the cycle repeats itself over and over again. The injury/reinjury cycle can be very hard to break, and makes overuse syndrome a difficult injury to treat.
It can take weeks, months or even years for overuse syndrome to develop. Onset occurs most often with a sudden and/or substantial increase in workload. A sudden decrease in time spent between massages can also precipitate the injury, as can changing technique or learning new techniques, or simply going through a period of psychological stress.
The primary symptoms associated with overuse syndrome is diffuse achiness, tightness and/or soreness in one part of the upper extremity, rather than sharp pain in one location that can be pinpointed. Twinges of pain may occur and may be quite severe, although short lived. Other symptoms include loss of function, particularly dropping things if the overuse syndrome is in the hands or arms, and the presence of paresthesias (numbness and tingling). Muscle bellies and tendons in the injured area may be tender and painful to the touch.
Classic signs of inflammation like swelling, redness and heat are generally not present in overuse syndrome. Steroids and non-steroidal anti-inflammatory medications (NSAIDs) have been found to be of limited efficacy in treating overuse syndrome, which supports the theory that inflammation is not part of the disorder.
In the early stages of the injury, pain may be mild to moderate and may be present only when the therapist is actually doing massage. Eventually, the severity of the pain increases and may also be present at rest and when using the upper extremity for other activities. Many therapists with advanced overuse syndrome experience pain while writing, brushing their hair, rolling down a car window, opening a jar, turning a faucet, or picking up a child. In the upper limb, overuse syndrome may begin in one arm and then spread to the other without any apparent cause.
Massage therapists suffering from overuse syndrome usually find that it takes quite a while for the injury to resolve to an acceptable level. Some find that it goes away after a while only to return repeatedly over the course of a few years. Therapists have reported recovery periods ranging from one to as many as five years.
Tendinitis/Tenosynovitis
Tendinitis and tenosynovitis are inflammatory conditions of the tendon and tendon sheath respectively. These injuries are caused by tearing (strain) of tendon fibers or irritation to the tendon sheath. Tendons attach muscle to bone near the fulcrum of movement (the joint), which is under great mechanical stress. If this stress is amplified by repetitive or improper use, the tendons are likely to tear. Their few nerve endings mean that tears may happen before the nervous system can respond and ease tension on the tendon. Their lack of sufficient blood supply causes tendons to heal slowly, with potential for uneven scarring and the subsequent formation of adhesions.
It is the clear presence of inflammation that distinguishes tendinitis and tenosynovitis from overuse syndrome. Among massage therapists, these injuries are less frequent complaints than overuse syndrome. Some classic, common tendinitis and tenosynovitis injuries are: lateral epicondylitis (Tennis Elbow), medial epicondylitis (Golfer??s Elbow), and deQuervain??s Thumb.
Tendinitis/tenosynovitis are associated with traumatic onset, as opposed to the gradual onset associated with overuse syndrome. The characteristic symptom of these injuries is localized pain generally worse with movement and better with rest. The affected area is often painful and hot to the touch. Swelling is common, and some loss of function may occur as well.
Nerve Impingement Injury
Nerve plexuses and their roots can be compressed, irritated, pinched or tugged on by the structures that surround them. Some assert that the basic cause of this impingement is overuse, and therefore categorize injuries like carpal tunnel syndrome and thoracic outlet syndrome as overuse or repetitive stress injuries. Impingement typically occurs in sites where nerves lie between hard structures (bone), or pass through or between softer, but still unyielding structures like muscle, tendon, ligament or fascia.
There are three nerves that innervate the forearm and hand: the median, the ulnar and the radial. These nerves can be entrapped at the wrist, elbow or shoulder. The median nerve may become impinged at the carpal tunnel of the wrist, or at the elbow by the pronator teres. At the elbow, the ulnar nerve may be entrapped in the cubital tunnel or in the condylar groove. The brachial plexus, the base of all three nerves, may be compressed at the thoracic outlet.
The two most common nerve impingement injuries among massage therapists are carpal tunnel syndrome and thoracic outlet syndrome. Muscle/tendon injury as a result of doing massage is more common among massage therapists than nerve impingement injury.
Carpal Tunnel Syndrome (CTS)
CTS has become a catch-all term that is too often applied to any pain syndrome anywhere in the wrist area. There are many other injuries that can cause symptoms at the wrist. CTS, however, has quite a specific definition: it is impingement of the median nerve at the carpal tunnel.
CTS occurs when there is ongoing pressure on the median nerve within the rigid, fixed space of the carpal tunnel, located between the carpal bones and the transverse carpal ligament of the wrist. This pressure, which can have a number of causes, cuts down on the volume of nerve impulses
travelling through the nerve to and from the hand. Mechanical pressure on the nerve can damage the nerve tissue, and can be a result of keeping the wrist in flexion for a sustained period of time, or placing the wrist against an object like a desk for sustained periods.
The classic symptom of CTS is pain felt in the palmar aspect of the wrist radiating into the hand, particularly the palm, the thumb, index finger, third finger and adjoining half of the ring finger (the innervation pattern of the median nerve). Another classic symptom, paresthesias, is experienced along the same innervation path. Like overuse syndrome, CTS tends to come on slowly, and can be triggered by a sudden increase in workload or decrease in the time allowed between massages.
Thoracic Outlet Syndrome (TOS)
The brachial plexus is a network of branches of spinal nerves C5-T1. In its course through the thorax, it passes between the scalene muscles and descends through the space between the first rib and the clavicle. This area at the base of the neck is called the thoracic outlet. After the plexus passes through the thoracic outlet, it descends into the axillary region (armpit) and branches into the nerves of the arm, the most important of which are the radial, median and ulnar nerves.
The thoracic outlet is a small, confined area like the carpal tunnel, containing many rigid structures. Abnormalities in any of these structures themselves, or in their position relative to each other, can cause the nerves of the plexus to be compressed and impinged. TOS refers specifically to impingement of nerves C8-T1 at the level of the thoracic outlet, which can create symptoms in the neck, shoulders, and all the way down the arm into the hands.
The primary symptom of TOS is pain in the cervical and suprascapular regions which may radiate down the arm, and sometimes headaches. Diminished nerve impulses can cause paresthesias and eventually weakening and atrophy of distal muscles along the nerve routes.
Poor posture is the primary cause of TOS. Sustained positions that change the relationship of the hard structures of the thoracic outlet to each other can decrease the space in the outlet and impinge the brachial plexus. Massage therapists tend to get TOS from working in a posture where the head is jutted forward and the shoulders are rounded. TOS can be an underlying contributing factor in other overuse injuries, and should be therefore be investigated when attempting to diagnose any upper extremity pain syndromes.
Preventing Injury
Left untreated or allowed to become chronic, any of these injuries can lead to partial or total disability of the hands and/or upper extremities, and affect your ability to continue practicing massage. It is therefore extremely important to understand these injuries, treat them, and change whatever postures, behaviors or techniques are causing them. Save Your Hands! Injury Prevention for Massage Therapists, offers massage students and professionals practical, medically-sound information, common sense tips, and real-life suggestions to help them prevent the injuries that are all too common in our profession. From stress-reducing, alternative massage techniques, to treatment options, to a strengthening and stretching routine designed especially for bodyworkers, Save Your Hands! is your best ally in maintaining a healthy body AND a healthy career. You CAN prevent career-threatening upper extremity injuries ?X Save Your Hands! shows you how.
Save Your Hands
(L. Greene)
Have a long, healthy massage career! Massage students and professionals alike will appreciate this practical, medically sound information on how to recognize, prevent, and treat injuries like carpal tunnel and tendonitis. This clear format presents stress-reducing massage techniques, a strengthening and stretching routine, and how to keep the demands of school and work from getting you injured