A Joint Effort

From acute injuries like tendonitis to chronic conditions like rheumatoid arthritis, joint pain is as common as it is vexing. Massage therapy can help.

 By Matt Alderton, November 1, 2022

There are 360 joints in the human body. Without them, you wouldn’t be able to walk, bend, kneel, squat, reach or run. You wouldn’t be able to golf, garden, paint, dance or swim. You wouldn’t even be able to sit down, tie your shoes or give a high five. Your joints aren’t just junctures, therefore. Rather, they’re tickets to mobility, movement and freedom.

But joints can be just as limiting as they are liberating—particularly when they’re sore, irritated and aching, which they often are, according to the U.S. Centers for Disease Control and Prevention (CDC). Because of arthritis alone, the CDC notes, nearly 15 million American adults live with severe joint pain. That’s joint pain measuring 7 or more on a 10-point scale, where 0 is “no pain” and 10 is “as bad as it can be.”

“Joint pain usually is the result of inflammation,” explains Saloni Sharma, M.D., medical director of the Orthopaedic Integrative Health Center at Rothman Orthopaedics in Bryn Mawr, PA. “It can be mild or severe, but when it becomes concerning is when it limits activities or functions such as standing, walking or exercising. If it impacts your ability to do even simple things like going to the mailbox or going to your child’s sporting events, that’s when we want to intervene and do something about it.”

In extreme cases, interventions might include medications, therapeutic injections or surgery. For many people, however, massage therapy can deliver fast, effective relief.

“Massage can do a great job loosening up the muscles and the myofascial tissue around the joint, which can help ignite the healing and recovery process,” continues Dr. Sharma, author of "The Pain Solution: 5 Steps to Relieve and Prevent Back Pain, Muscle Pain and Joint Pain Without Medication."

Princeton, NJ-based rheumatologist, internist and integrative medicine specialist Aly Cohen, M.D., agrees. “Hands-on approaches to physical ailments are remarkably helpful if they’re done well,” says Dr. Cohen, who also is an environmental health specialist and founder of TheSmartHuman.com. “If it’s not an acute issue that requires hospitalization or medication, you want to let the body heal itself—and massage can help facilitate that.”

Doctors like Sharma and Cohen have seen firsthand how massage therapy can improve joint health and function. To maximize its efficacy, they say, massage therapists should understand the myriad causes of joint pain and the unique physiological pathways through which massage can address them.

Arthritis, Bursitis, Tendonitis—Oh My!

Joint pain can be either acute or chronic and either local or systemic. Before they work on someone who complains of sore joints, massage therapists should, therefore, determine what kind of pain the client has, says massage therapist and personal trainer Drew Bales, LMT, BCTMB, CPT, owner and operator of Fascia-Fit Manual and Movement Therapy in Oak Park, IL.

“If I’m dealing with a tendon or ligament injury, I’m going to use one set of modalities or techniques. If I’m dealing with someone who has systemic chronic inflammation, I’m going to use another,” Bales says.

On one end of the joint pain continuum are acute injuries like tendinitis, which is inflammation of the tendons that join muscle with bone. Sometimes known as tennis elbow, golfer’s elbow, pitcher’s shoulder, swimmer’s shoulder and jumper’s knee, it typically stems from overuse—often by people who have jobs or hobbies with repetitive motions.

Repetitive motions also can cause bursitis, which is inflammation of the bursae—small, fluid-filled sacs that protect joint-adjacent bones, tendons and muscles. Uncomfortable positions like kneeling or leaning also are common culprits.

On the other end of the joint pain continuum are chronic issues like osteoarthritis and rheumatoid arthritis. The former happens when the cartilage that cushions the ends of bones in your joints erodes, eventually causing bone to rub against bone. The latter is an autoimmune disorder wherein the immune system attacks healthy tissue, including the lining of one’s joints.

Other chronic causes of joint pain include lupus, another autoimmune disorder; gout, a complex form of arthritis wherein uric acid crystals form in and around the joints; and Lyme disease, a bacterial infection that can spread to the joints.

Somewhere in the middle of the joint pain continuum are postural dysfunctions that can be a source of either acute or chronic pain—for example, forward head posture (FHP), otherwise known as “text neck,” which describes neck pain from prolonged bending of the head toward a computer or smartphone screen.

Whatever the condition, massage therapists who understand the mechanics of joints are well positioned to deliver relief, according to Dr. Sharma. “There are so many factors besides the actual bony joint that can cause pain, including muscles, ligaments, tendons and cartilage,” she says. “So even if you don’t know the exact cause of pain, you can often help just by working on the supporting structures surrounding the joints.”

Take osteoarthritis of the knee. “One of the key therapeutic recommendations is physical therapy with the goal of strengthening the muscles and tendons both above the knee and below it,” Dr. Cohen says. “Because if you strengthen the structures around the joint, it gives the knee more support.”

Like physical therapy, massage can help the anatomy around joints function properly, Drs. Sharma and Cohen agree. And when the anatomy around them functions properly, joints experience less stress and increased range of motion, the effect of which is reduced pain.

A Healing Touch

If someone has a new acute injury like a broken bone, a sprain or a fracture, massage may exacerbate instead of alleviate pain. Before you work on a client with joint pain, therefore, it’s important to make sure they’ve seen a physician who has cleared them for massage, Bales advises.

“If it’s too early in the acute stage of an injury—if you can see that it’s swollen and feel with your hand that it’s warm—then treatment is contraindicated,” he says. “You’re only going to make it worse.”

If a client is cleared for massage, massage therapists have myriad techniques at their disposal that might be able to help.

Swedish Massage. Start with simple Swedish massage, suggests massage therapist Tronda Graham, LMT, owner of Align Total Wellness in Louisville, KY. “Basic effleurage—just gliding over an area—is helpful because it increases blood flow, and healthy blood flow promotes healing,” Graham explains.

Along with blood flow, effleurage increases the flow of lymph, points out massage therapist Maureen Davis, LMT, co-owner of Blue Wave Physical Therapy & Wellness Center in Metairie, Louisiana. “Our lymph system is our immune system,” Davis says. “Relieving any stagnation in our lymph nodes and recirculating that fluid is positive because it helps with inflammation, whether that’s localized inflammation or whole-body inflammation.”

That can be particularly beneficial for people with autoimmune diseases like rheumatoid arthritis, who may experience poor lymph flow as their disease progresses.

Because it activates the parasympathetic nervous system—the body’s “rest and digest” response, which may modulate pain signals caused by the “fight or flight” response of the sympathetic nervous system—the secret to successful Swedish massage for joint pain is long, slow strokes, says massage therapist Kyrie Burrus, LMT, owner of Penn Valley Therapeutic Massage in Penn Valley, CA. “I find that a gentle, moderate pressure and a slow progression can help put people in a parasympathetic state,” Burrus says. “Going too fast or too deep can startle the muscles and make the body feel like it has to protect itself.”

Hot and Cold Therapy. Heat also activates the parasympathetic nervous system. For that reason, Burrus also likes to use hot stone massage. “It’s about working smart, not working hard,” she says. “The heat works on a deeper level to loosen the muscles, and the different shapes of the stones allow you to get in closer to the joints themselves.”

A combination of hot and cold stones—or heating pads and cold packs—also can be effective. “The combination of hot and cold increases circulation,” Burrus continues. “And again, anything you can do to bring more blood flow to the area is going to help alleviate pain by reducing inflammation.”

Myofascial Release. For Bales, a go-to technique is myofascial release. Like Swedish massage, it can be an effective way to stimulate the movement of lymph in people with systemic joint conditions. “The main benefit of myofascial release for chronic systemic inflammatory diseases is to improve the immune system by manipulating lymphatic fluid through the body to the lymph nodes,” explains Bales, who also uses myofascial release on clients who have joint pain from postural dysfunctions. “Myofascial release is helpful for that because it works on structural alignment.”

Bales likens the fascia around muscles to a sausage casing. When people experience joint discomfort from postural dysfunctions, they change how they move to avoid pain. When the fascia adapts to their new, limited movements, it’s akin to shrinking the sausage casing. As a result, the muscle can’t expand and contract the way it’s supposed to. Over time, that causes one to lose flexibility and range of motion, which creates new pain on top of old pain. Myofascial release may help restore muscle function by elongating fascia.

“Myofascial release is done dry with no lubricant,” Bales explains. “The reason for that is you need grip and traction to lengthen the connective tissue around the muscles. It’s like pulling taffy. That’s what you’re trying to do to the fascia. You’re literally trying to stretch the casing so the muscle fibers inside it have more space to lengthen, which allows the joints to move into better alignment.”

Again, slow strokes work best. “If you’re trying to treat an area and you’re moving really fast, the body’s going to tense up,” says massage therapist Christine Grimes, LMT, owner of Maine Medical Massage in Auburn, ME. “If you work slowly, the body will unwind and allow you to get beyond its natural defenses.”

Trigger Point Therapy. Grimes likes to pair myofascial techniques—slow, deep strokes with static pressure and muscle stripping—with trigger point therapy, wherein the massage therapist targets muscles in places that are strained as a result of continuous pressure.

“Even if there’s something wrong with your joint, like arthritis, that’s not necessarily the cause of your pain,” Grimes says. “Take, for example, the knee joint. There are seven different trigger points that have referral pain patterns that go to the knee, and those can be treated very easily with massage therapy.”

Cross-Fiber Friction. For acute conditions like tendonitis, Bales suggests cross-fiber friction, which is thought to stimulate a localized immune response that improves and accelerates the healing of injured tendons, ligaments and muscles.

“With friction therapy, I’m going to identify the soft tissue that’s injured, then I’m going to friction in the opposite direction that the fibers run,” Bales explains. “I’m not going to scrub back and forth. I’m going to start at one end, pin, then pull through.”

Don’t forget about …

Whatever technique you use, there are four things that can make massage therapy for joint pain even more effective, massage therapists agree.

The first is stretching. Performed before a massage, dynamic stretching loosens tight muscles to prime them for massage, Graham says. Performed after, static stretching lengthens soft tissues in order to amplify massage therapy’s benefits, Bales says.

“After a massage, the soft tissue is in a nice, soft, supple state,” Bales explains. “If I don’t lengthen that tissue, then three hours later it’s going to cool down and it’s going to stay the same length it was. When I spend the last 10 or 15 minutes of a session stretching the area I worked on, I lengthen the tissue—and it stays lengthened.”

The second thing massage therapists should keep in mind is communication. “We don’t have X-ray vision, so we need to communicate with the client by asking lots of questions and doing lots of check-ins,” Davis says. “We need to know if the pressure’s too much and if we’re working in the right places. Because you don’t want the client to be in pain on the table—ever.” 

Because you don’t want clients to be in pain off the table, either, aftercare is also important, Burrus and Grimes agree. For example, massage therapists might suggest certain yoga poses or stretches, hot baths, or self-massage using a foam roller or tennis ball.

A fourth and final consideration when working with clients with joint pain is cross-disciplinary collaboration. Davis, for example, shares her practice with her sister, who is a physical therapist. Bales brings to bear his experience in sports medicine and physical training. And both Drs. Sharma and Cohen—who work in orthopedics and rheumatology, respectively—say they’d like to see more teamwork between massage therapists and physicians.

“There absolutely should be a partnership, and that partnership should include massage therapists,” Dr. Cohen says. “You shouldn’t have to go to one person for your knee and another person across town for your neck, because everything’s connected. When you work together across silos, that’s how you treat the whole person.”