Massage therapy unquestionably incorporates whole body strength and movement, but the hands and wrists are perhaps the stars of the show. So preventing injury is crucial to career longevity—your ability to do your job effectively for as long as you choose.
“We have to take care of our hands so we can take care of a lot of people,” explains Dennis Price, a massage therapist in Fort Lauderdale, Florida. “These are the tools of our trade. If we’re not taking care of ourselves, why should clients come to us?”
Let’s delve into some of the most common hand and wrist injuries faced by massage therapists, as well as self-care strategies to help protect against them.
Role of Hands and Wrists in Massage
In contrast to most body areas employed in massage, the wrists and hands involve dozens of distinct moving parts. Each hand contains 27 individual bones that offer the hand a wide range of motion, with the ulna and radius converging in the wrist and supporting myriad muscles that manipulate both wrists and hands.
The eight small carpal bones in each wrist are joined in two equal-length rows to form the carpus, which is rounded on its proximal end to articulate with the ulna and radius. Tendons, ligaments and nerves run into the palm through the carpal tunnel, which is formed by the canal on the palmar side of the carpus. The five long, thin metacarpal bones of the palm extend from the carpus to each of the fingers in the hand.
With all of these separate components at work in massage therapy, is it any wonder that injuries among massage therapists are highly common?
“The muscles that provide most of the movement of the fingers are in the forearms,” says Becky SanGregorio, a massage therapist in Ebensburg, Pennsylvania, and director of education for Save Your Hands! A Guide to Injury Prevention and Ergonomics for Manual Therapists. “The relatively strong flexor and extensor muscles start at the elbow, but stop mid-forearm and connect to the fingers through tendons. Most of these tendons pass through the carpal tunnel.”
“The wrist is a complex mechanism with many moving parts in one small area, so it is also vulnerable to injury outside of the carpal tunnel,” she continues. “Tendons on the extensor side of the wrist can become irritated by tight muscles rubbing across them. The median nerve can even be damaged as it exits the carpal tunnel at the base of a massage therapist’s palm.”
Potential for Injury
SanGregorio, Price and other massage therapists emphasize that improper alignment of the wrists, hands and especially thumbs poses the biggest potential for injuries. “Massage therapists may think the thumb is the strongest and most useful digit for applying pressure. They are conveniently short and—unlike fingers—they have stabilizing muscles at their base to help support them,” SanGregorio says.
But the unique structure of the thumb makes it particularly vulnerable to injury, she notes. Forces acting on the thumb are concentrated in the carpometacarpal (CMC) joint, the saddle joint at the radial end of the carpal bones that makes the thumb opposable. As the muscles at the base of the thumb contract to stabilize the joints while pressure is applied with the tip of the thumb, the metacarpal bone is pulled down into the CMC joints, creating pressure there, she says.
“For every pound of pressure that a massage therapist applies with their thumb, there can be 10 to 12 pounds of pressure concentrated on the CMC joint,” SanGregorio says. “So if a massage therapist uses their thumb to apply 10 pounds of pressure on a stubborn trigger point, the result could be as much as 120 pounds of force at the base of their thumb.”
Massaging with a bent wrist is also a big no-no, SanGregorio notes. “It stretches muscles and tendons and puts everything out of alignment,” she says.
Common Hand and Wrist Complaints
Price says injuries among massage therapists fall into two main categories: overuse or misuse. Tendon injuries are harder to heal, partly because blood flow to tendons is limited and “inflammation takes longer to calm down,” he says. The most common hand and wrist injuries in the field include:
Commonly referred to as DeQuervain’s tenosynovitis, this involves inflammation of the lining of the sheath covering tendons. It can happen in any joint, but most often affects the wrists and hands, resulting from strain and overuse. Symptoms include swelling, pain, redness and difficulty moving the affected joint. “Prevention is always best, and the nutrition part of that is getting enough omegas and oils,” Price says. “Warming up [before client work] is also important. The body is like a hydraulic system . . . and with the synovial joints, if we move around, with three-quarter range of motion, it bathes the joints with fluid so the joints aren’t irritated when the tendon moves across it."
Saddle Joint Injury
The thumb’s basal, or CMC, joint is saddle-shaped, formed by the trapezium in the wrist and the metacarpal in the thumb. This distinctive shape enables the thumb to rotate up, down and across the palm, and to pinch. Saddle joint injury can present with throbbing pain or a dull ache, Price says, and treatment involves resting it and using anti-inflammatory medications both topically and orally. “If a therapist is gliding with their hand and their thumb goes out to the side and pulls back away from the rest of the hand, having the joint in that extreme position puts a lot of strain on it,” he says.
Carpal Tunnel Syndrome (CTS)
One of the most prevalent injuries suffered by massage therapists, CTS results from the median nerve becoming compressed at the wrist. Since the median nerve provides feeling to the palm side of the thumb and also the index, middle and part of the ring finger, this compression can cause burning, tingling, itching, pain and/or numbness in most of the hand. Symptoms often appear during the night since many people sleep with flexed wrists. Decreased grip strength results, posing major difficulties for massage therapists while working on clients.
“The position of the hands is key. A lot of massage therapists put their palm down and use too much pressure at the wrist/palm area, and ride that pressure to get greater weight on a muscle,” says Glen Kemp, a massage therapist in Tampa, Florida. “When you impinge on that area, you’re creating a situation that almost guarantees inflammation.” Treatments include splinting, avoiding symptom-provoking movements, medications and surgery.
How Injury Hurts You—And Your Practice
A major focus for many massage therapists is treating their clients’ carpal tunnel syndrome. So it’s ironic, Price says, that CTS “is a problem many massage therapists end up experiencing. It’s one of the reasons a lot of people drop out of the profession, and it’s largely avoidable.”
Therapists who regularly perform deep tissue, trigger point or neuromuscular massage are particularly prone to injury as well, therapists say, because their movements involve more rigorous use of the hands and wrists. This risk is magnified if you don’t regularly vary the techniques you use or vigilantly monitor your posture and alignment. “You have to check in with yourself and make sure you’re not putting yourself in awkward positions, like keeping your elbows tucked into your body and your feet in the proper position,” says Toni-Ann Accardi, a massage therapist in East Rutherford, New Jersey. “Move your body to make the stroke, as opposed to pushing and pulling with your arms.”
While pain and limited movement are among the biggest problems related to injury, also looming large is any necessary recovery time and how that may affect your practice. Career longevity is at stake when you have to stop work or cut back because of nagging injuries. “It is one of the largest factors, if not the largest primary factor, that can cause people to drop out of the profession,” Price says. “Forearm, wrist and hand pain can literally end a career and has done so many times.”
Price also points out that taking even short periods of time off can drive clients to other massage therapists, costing you business. “And if you can’t use your hand because it hurts, the quality of the massage is not as good . . . [and] the quality of our treatments end up being our reputation. This is definitely one of the issues that can be a career-changer and critical to career satisfaction.”
Practicing Smart Self-Care
In addition to practicing neutral postures and positions, a bevy of preventive techniques comprise a solid self-care regimen for the wrists and hands. These include:
- Warm-up stretching before the workday: “Rotate wrists and open and close hands for a minute or two, then stretch warmed-up tissues,” Price advises. “If you’re already tense, your flexors are going to be tighter. Movements get fluid in the joints and loosen up muscles, tendons and ligaments along the joints.”
- Utilizing effort-sparing tools: Kemp works on clients using an electric table that changes positions effortlessly, reserving his own strength. “I can control the angle of pressure more effectively, so I can get at least one more massage out of my workday,” he says.
- Spacing out your workload: “I won’t work more than four days a week, and no more than 5 hours in a day, and I leave a half hour between each client,” states Accardi, whose own carpal tunnel syndrome prompts her to stay on top of self-care.
- Using ice, heat and other anti-inflammatory measures: Kemp dips his hands in paraffin, among other daily tactics. “I go home and apply ice after a rough day to ease inflammation,” he says, “so I use a lot of heat and cold.”
Trading services with colleagues: “There’s nothing better than collaborating with the massage therapists in your area to treat each others’ forearms,” Price says.
“Proven methods exist to lower the incidence of work-related injury,” SanGregorio says. “Many of them involve making simple but important changes to your activities, both at work and elsewhere; others will take more thought and practice to apply. While injury is common among massage therapists, it is certainly not a foregone conclusion that it will occur.”