Hip- and knee-replacement surgery offers a path to pain-free mobility for people whose joint function has diminished due to age, illness, activity or injury. It’s no surprise, then, that the popularity of these procedures is surging: A 2019 study in The Journal of Rheumatology projected that the number of total knee-replacement surgeries performed in the U.S. would jump from about 1 million in 2020 to more than 1.9 million in 2030; total hip replacements were expected to jump from about half a million to 850,000 in the same period.
Arthroplasty procedures can provide meaningful long-term benefits to patients, but they usually also come with long and arduous recoveries. Massage therapy can play a crucial role in the recovery process.
“Post-surgical massage can soothe the guarding reaction of tissues, helping them to return to normal function. In effect, one is communicating to the [central nervous system] through the tissues that the trauma is past, and that the nervous system and tissues can return to pre-trauma normal,” says John Chamness, LMT, a massage therapist at NorthShore University HealthSystem in Chicago.
Additionally, lymphatic drainage massage is useful in reducing both pain and swelling, and should in many cases be considered a core part of the broader post-surgical therapeutic protocol, according to a 2020 review of more than 70 prior research studies in the Journal of Bodywork and Movement Therapies. A separate 2020 study published in the International Journal of Rehabilitation Research found that lymphatic drainage used in combination with kinesiotaping proved effective against both pain and edema following total knee-replacement surgery.
Massage can also address other common post-surgery issues, such as the buildup of scar tissue that often accompanies hip and knee procedures.
“Scar tissue can be made more pliable and functional by realigning it in the direction of desired stretch,” says Chamness. “Muscle dysfunctions such as trigger points can be released to allow the muscles to both fully stretch and regain maximal contraction and strength. All of this can increase joint ease and range of motion, and reduce pain—and it supports and helps with physical therapy goals.”
But post-surgery massage also comes with unique challenges. Joint-replacement surgeries are unavoidably traumatic, sometimes involving intentional cuts to bones, muscles and tendons, as well as joint dislocation. Then there’s the new joint itself, an artificial element that takes time to fully bond and integrate with the patient’s body.
Because of these dynamics, the first order of business for massage therapists is to coordinate with the patient’s larger care team, from physical therapists to orthopedists. An orthopedic surgeon, for example, might have specific instructions regarding when it is acceptable to begin massage near the affected area, or regarding appropriate range of motion for the affected joint. The PT team can provide progress updates and identify areas where the patient may benefit from more extensive soft-tissue work.
“You’re asking, ‘What are you working on with this patient? Are there specific precautions, or things you would like me to focus on, or that you don’t want me to do,’” says Matthew Gavzy, LMT, a massage therapist and physical therapist assistant at Churchill Orthopedic Rehabilitation in Teaneck, NJ.
That’s in part because other rehab providers recognize the benefits that time-intensive, concentrated massage can provide—not only massage near the surgery site, but also on other affected areas.
“If somebody comes in with a total knee replacement, often their knee is swollen and stiff and they’re working on the range of motion—but so many other parts of the body are also affected, from ankles to the hips and the back,” says Gavzy. “The massage therapist has the ability and time to really work on those issues affecting the whole body.”
High Value, High Risk
Two of the most common pathologies that lead to joint-replacement surgery are osteoarthritis and inflammatory conditions such as rheumatoid arthritis. Osteoarthritis, often brought about by aging, is marked by the gradual wearing down of cartilage. In the hips and knees, osteoarthritis can be exacerbated by obesity. Inflammatory arthritic conditions, in contrast, are marked by inflammation of the tissue surrounding the joint, often causing patients to experience pain, stiffness and swelling.
Many people struggling with either osteoarthritis or inflammatory arthritis turn to massage therapy for relief before resorting to surgery. That means that by the time they head to the hospital for a joint-replacement procedure, there’s already a strong relationship in place with a massage therapist.
In those cases, the partnership with the broader care team can begin before surgery, with massage aimed at softening tissue with myofascial release prior to the operation, as well as screening for muscle- and tissue-related issues, such as leg-length discrepancies.
“You want the patient to go into surgery with the weight-bearing structure as neutral, balanced and functional as possible,” says Chamness.
Post-surgery, massage therapists should defer to guidance from the orthopedic or physical therapy teams regarding when to begin massage near the affected joint—often about six weeks after surgery. Until that time arrives, it’s best to focus massage efforts away from the site. Chamness, for example, emphasizes craniosacral therapy in the days immediately following surgery. Lymphatic drainage massage away from the affected area can also be helpful in the days immediately following surgery.
Once the time comes to focus on the affected area, it’s important to understand what happened during surgery. There are several versions of hip-replacement surgery. There’s hemiarthroplasty, for example, where an artificial femoral head is inserted into a patient’s existing acetabulum. Some patients will have total hip replacement, where part of the acetabulum is also replaced with an artificial socket. There are substantial differences between an anterior hip replacement and a posterior procedure—surgeries using a posterior approach come with much longer rehabilitation times and more postoperative precautions.
Patients recovering from posterior hip replacement often have range-of-motion restrictions and are not supposed to bend their hips beyond 90 degrees, cross their legs, or allow their feet to drift into a pigeon-toed position. It’s imperative that massage therapists understand and abide by the restrictions—even when the patients don’t object.
“The patient might know where they are and aren’t supposed to go, but on your table, you’re the professional—and if you ask them to go farther than that, they might trust you and do it anyway,” cautions Chamness.
Additionally, it’s important for massage therapists to consider whether their preferred techniques and positions are compatible with a post-surgery patient’s restrictions. Bolsters, for example, might place undue strain on a delicate knee, while a low table might be too painful or awkward for a patient to navigate. A side-lying position is out of bounds for patients recovering from posterior hip replacement because their legs aren’t supposed to touch one another or cross.
With the appropriate precautions, massage can prove to be an invaluable part of the recovery process. Once therapists are permitted to access the area surrounding the joint, they are able to promote healing more directly, both with lymphatic drainage massage and with soft-tissue massage aimed at breaking up scar tissue. Both of which are delicate work.
“When I get to that post-surgery site, at first I just palpate and work some of the lymphatic fluid, just see how it’s moving in there,” says Lorraine Ross, LMT, owner of Lorraine Ross Massage in Punta Gorda, FL. Ross starts with superficial massage before working deeper, addressing trigger points. As the rehab process extends over weeks and months, she also pays close attention to the leg that was unaffected by surgery, to see if there are emerging compensation issues that need to be addressed. Likewise, if she notices abnormal behavior in affected muscle groups—one typical post-surgery issue she’s noted is the gluteus maximus not firing at the right time—she’ll alert the physical therapist so that the patient’s rehab program can be adjusted accordingly.
Chamness says that after a knee replacement, he always takes care to check on the adductor muscles.
“Those muscles seem to be involved for pretty much everyone, and pretty much everyone benefits from having them worked out,” he says.
Patients seeking massage after hip- or knee- replacement surgery pose some unique challenges for therapists, from the trauma of surgery to the physiological complexities of artificial joints, not to mention the coordination required with other care providers. Working with post-surgery patients can require a little extra effort, but it’s well worthwhile considering the potential effect on their recovery and well-being.
Tips for Care-Team Coordination
One of the most crucial—and helpful—aspects of post-surgery massage is coordination with the rest of the patient’s care team. For massage therapists practicing in an integrative setting, such coordination is as straightforward as looking up the patient’s electronic health record and accessing the notes from a recent physical therapy session.
“Having all those different perspectives and all of that data just feeds into what I am considering doing, and helps me have a better idea of what to do,” says John Chamness, a massage therapist who has worked for the last 17 years as part of an integrative practice at NorthShore University HealthSystem in Chicago.
A little more work is required of massage therapists who don’t have that sort of built-in access, yet it’s still an essential practice. Ask for treatment notes, and whether there are particular areas that could benefit from soft-tissue work. It’s also smart practice to convey your experience level and the relevant services you’re able to provide, such as increasing range of motion.
“The feedback I get from physical therapists is that they are glad their patient is working with a rehab-focused massage therapist, because while they know [massage] is something the patient needs, they do not have the time to give it. We can fill in that gap,” Chamness says. “What we can consistently offer is the ability to spend as much time as the patient wants, focused solely on the patient, providing normalizing, healing soft-tissue manipulation.”