Deep Tissue Issues: No Pain, No Damage

Deep Tissue Massage is a term that is both comforting and productive when you think about getting a massage.  As a client, you might want to “get out the knots” or “alleviate pain” in a particular area of your body.  As a therapist, there is a plan, a particular intent to achieving a successful feeling of relief for your client at the end of a massage or a series of massages.  But the client takes a risk receiving a deep tissue massage from a therapist they haven’t worked with before OR from whom they’ve never asked for a “deep tissue” massage.  This article addresses method, concerns, and resolutions to requesting, anticipating, and giving & receiving a deep tissue massage, for clients and therapists.

The Plan

Clients often respond to their therapist’s question “What areas would you like me to work on today?” with designating specific areas that they have recently been feeling pain in or having issues with.  It is common for the therapist to devise a plan to address those areas with some specific work, using a specific method.  This need expressed by the client and solution presented by the therapist is very often verbally communicated, but sometimes is expressed through body language during the massage session.

Your massage therapist can and should comply with verbal direction…immediately. It is critical that for a successful session, for the client to experience relief without pain, that the therapist be aware of the boundaries of the muscle that s/he is addressing at any given time.

Intent. Deep Tissue massage, when done correctly, allows the most pressure to be delivered for proper physiological response – a “release” to occur – and leaves the tissue specifically worked undamaged.  Too much pressure can damage tissue, causing micro-tears in the fibers or bruising.  Too little pressure is simply ineffective for the purposes of release and resetting of the fibers.

What It Is. Many times, therapists will ask a client “do you bruise easily?” to clarify the client’s propensity for damage to the tissue, if they are aware and may have a prior experience with bruising after a deep tissue massage.  The client may be advised that, if they do bruise easily, that it may be a result of the deep tissue work they’re about to perform, the unusual pressure that will be delivered to any specific area, and that the response or failure of the tissue to release during or before the eventual lengthening effect the work will have this effect.

What it “could be”. Most times, it is the non-verbal communication by the client that presents a challenge to the therapist in understanding what muscles and systems need and have the ability to be addressed on a deeper level, by both the client and the therapist.  I believe that effective, non-verbal communication is crucial to delivering a well-planned and effective deep tissue session.

Receiving a Deep Tissue Massage

for the massage client

During the massage, although you may have a ‘knee-jerk’ reaction initially, first try to consciously and verbally express any discomfort – you may allow the therapist to “dig in” and allow the elbow, knuckles, or pointed tool (like finger tips), to access the areas where you’re feeling the chronic or acute pain, thereby increasing the sensation of pain that often accompanies the massage work.  BUT, if you anticipate or there is sharp pain or increased, persistent pain, you should tell your therapist…it is commonly understood by therapists: this is not the intent of deep tissue massage.

Why not? When there is pain, the body automatically (on a conscious or unconscious level) enters a protection mode – during this time, the brain is trained to respond to the type of pain in the area of the body where it is being experienced, and will, over time, automatically respond in the same, defensive manner by splinting, or tightening up, the muscle that is being targeted for massage.  When a muscle is engaged, or shortened, massage has a substantially less (if any) effect on the targeted, now short, muscle.

Since the intention of a [deep tissue] massage is to relax, or lengthen, muscles, this response to pain – the shortening, contraction, or engagement of the muscle, (spoken or not, conscious or unconscious) does not help the tissue or the therapist to get where they need to be, organically or procedurally, to release the tissue.  Longer times or multiple sessions with the same muscle are needed for massage therapy to be applied if the threshold of pain is crossed too often, resulting in little or no effect on the target muscle or muscle group.

Pressure needs to be lessened or another technique used to relax the tissue, so ‘deep tissue’ becomes a modality that is ineffective if it is no longer used during the session due to the body protecting the muscle.

So, communicate verbally and non-verbally with your therapist so s/he understands that deep tissue massage techniques are or are not appropriate at the right times.

for the massage therapist

Clients may not understand, be able to tell you, or even want to tell you about the pain they may be anticipating or actually experiencing because s/he may believe it is a part of the healing process.

Therapist Awareness. Beingness can be defined as the therapist’s state of awareness – a ‘listening’ state – that includes anticipation of what the tissue needs (or doesn’t, when it comes to pressure) – simply being aware of how the tissue reacts to touch, pressure, and manipulation is SO important.

Before the session. To avoid micro-damage to the targeted muscle or surrounding area and to avoid any long-term discomfort from the massage or a complaint phone call, explain to them your understanding of pain as associated with deep tissue massage, ask their understanding, and then come to an agreement of what it is that’s in your scope to practice and what they can expect to be a “deep tissue” massage from you.

Coach them on how to communicate with you during the session, verbally.  It is much better to be able to respond immediately to verbal and non-verbal cues from your client – be in a ‘listening state’.

Always ask for feedback if you felt the session was intense for your client, based on their comments or their body language.  It is better to address the concern closer to the session on which the feedback is based so you can effectively help them recover, avoid, or even expect what they may perceive as a negative experience.

  • If you get feedback immediately following the session, respond immediately: a simple suggestion on how to clear the interstitial space that harbors blood causing the appearance of a bruise will help them recover more quickly.
  • Ask them to wait a few days to update you or observe how they feel: often times the client will feel much better than before the massage, even though there are some sensitive bruises present.

If you get feedback from your client that they bruised last time you worked on them, be ultra-sensitive to that fact and recall the amount of pressure you delivered last session with him/her and start off with conservative pressure.  The client should be able to remind you or make you aware of any thresholds they are getting ready to cross based on their experience with you.  Compassion and action will guide you to deliver a conservative yet effective pressure.

some explanations of a “bad” deep tissue massage

Therapist Inexperience. There is one saving grace for a therapist that technically is not experienced or experienced enough in a client’s eyes.  That is: the ability to ‘listen and act.’  Verbal and non-verbal cues given by a client receiving deep work are ALWAYS important information that a trained therapist needs to be able to act on.  A good therapist, no matter their tenure in practice, will immediately respond/act on the client’s given information.  How they act can always be in the best interest of the health of the client.

Client Inexperience. In my experience, when someone tells me they ‘like it really deep’, a flag goes up…the acceptance or need for pain to achieve a psychological level of relief is not within my scope as a massage therapist to address, and this is something I advise my clients of.  So, here are some of my thoughts on ‘why people tell their next therapist that they’ve had massage that hurt in the past:’

On the other hand, in the case a client does not like pain as a side-order of their deep tissue massage, I believe some clients wait to tell their next therapist that their last massage was “too deep” for any one or more of these reasons:

  • Politeness. They may not have been able to mentally bring themselves to tell their last therapist during the session.  It’s not the therapist’s fault or it’s not in the client’s nature to say something to cause what the client his/herself would perceive as conflict in an environment that they want to be stress-free.  If the MT did a good job of creating that environment of relaxation and trust, then the last thing I think the client wants to do is rain on anyone’s parade.
  • Bad Customer Service. Generally, “bad” experiences are related more quickly and often than good ones – it is a customer service fact, proven time and time again in many types of business, including a massage therapy practice.  It could be a form of release for the client, but if we communicate with and coach them to properly assess and classify their massage experiences, there’s less reason for the client to complain to the next MT (who can themselves literally do nothing to change the client’s previous experience).

Be a Proactive Therapist When Faced With A Complaint About “My Last Massage…”

Here are a number of things I may ask of and communicate to a client that has had a bad deep tissue experience and who is now relating it to me:

1.      Empathize/Sympathize with his/her situation

2.      Educate, through asking key questions, like:

a.      “Did you tell your therapist?  If you did, then you need to stop the session next time

b.      “Did you tell your therapist afterward?  There might be other considerations in your physical condition that the therapist can further advise you on how to resolve if massage causes pain for you…”

c.      “Did you drink enough water before your massage? (Do you think you might have been dehydrated?)“…and then tell them the effects of ‘not enough water’ on tissue during a massage…

d.      “Did you have an injury in the area or anomaly that you didn’t have in previous sessions that could have been negatively affected by massage?”  The client could have a condition that they don’t know about of which peripheral neuropathy is a symptom, like Fibromyalgia Syndrome or Lupus or Diabetes.  Or they could’ve had a couple of alcoholic drinks or were on medication that reduces mechanical sensory input.

e.      “How long was it since your last massage (before your bad massage)?“…and then tell them about tissue memory & elasticity and how ‘getting back into the groove’ can be a factor in what depth they can receive after a long stay away from deep massage.

3.      Define my relationship with this client (in so many words, and without saying: I am not “their last therapist”) – assure him/her that I will be aware of their needs and requests at all times during the deep tissue massage.

Avoid a potential ‘bad’ massage because of ineffective communication

A massage therapist’s depth can be perceived as invasive, intrusive, and inconsiderate, BUT – when I understand why Clients complain to the next therapist, I realize there is NOT A THING I can do about it…eg. to change their behavior.  All I can do is change my own.  Following are some scenarios I’ve experienced and consider when I think there is [going to be] a ‘too deep’ issue:

1.      Problem: The client didn’t tell the therapist ‘it’s too deep’ – It could be that the client didn’t feel like they could say anything to their MT about the discomfort – maybe they didn’t feel like their feedback would be welcome.  so they go ahead and receive a massage that’s ‘too deep’.

Solution: In reply to the question “how’s that pressure?’ a client says “good” in that monotone voice, change something: either go deeper, change speed, go lighter, slow down – something’s not satisfactory to the client.  Now: you can’t squeeze it out of them, so ask again about the pressure at another point – while you’re touching the client, doing the deep work.

2.      Problem: They haven’t had a massage in a while – often, getting a massage after not having one for a while is like getting back into the gym after you’ve been out several months after previously going 3 times a week.  Muscles are stretched, poked, and pressed…and the fibers are not always as flexible or elastic as the client thought they would be.

Solution: Preset your ‘deep scale’ to a lighter mode – and tell them that’s what you’re doing!  If you set the expectation, they will be happy…because what you said would happen, is happening during the massage 🙂

3.      Problem: The client didn’t drink enough water before the massage – water is a medium that is essential for the muscle tissue and fascia to move easily over itself.  Without the lubricant internally as well as externally, friction causes irritation and possibly inflammation on, at least, a microscopic level…thus, the discomfort.

Solution: give them water – tell them why you’re suggesting water for them…that minute!  Explain that preparing for a massage with drinking water can reduce the pain they might experience after a deeper massage.

4.      Problem: The client is experiencing changes in their metabolism or other physical changes are occurring.

Solution: be aware of conditions, considerations, and contraindications for doing massage.  If you have a question about practicing on a person with or in a particular condition, you might always want to preface

Some bottom line solutions for me, as a massage therapist:

  • I am open to constructive and even negative criticism – I realize that I am there to facilitate his/her healing.
  • If I don’t exercise due diligence in making sure at any point that my client is happy with the pressure, I risk a client complaining later, either to me (after the fact) or to another therapist.

Ultimately: What Works

Some clients like the ‘hurts so good’ feeling, and they always are sore the next day – this can be a sought after feeling for some clients who psychologically are subjecting themselves to pain inflicted by another for something that is out of the scope of the MT’s control.  Maybe after they’re sore the next day, the following day they feel great!  This could be a method of healing for them, psychologically and physically.

There are conditions that I’ve seen that benefit from being sore during the massage or even the next day – one condition of the client is that of fibromyalgia.  FibroMyalgia Syndrome (FMS) patients take the pain in order to feel great the next day – there are some FMS patients that have enough experience to realize that the positive effects of the pain experienced during a deep tissue massage are worth experiencing the pain of the moment (during a massage, deep tissue or otherwise).

When I look at the overall meaning of the term “deep tissue”, it means to me a level of awareness and that I need to have a heightened sense of listening and responsiveness to my client’s needs.  When a client requests this as a modality (on a menu, for example) I think they have been trained to understand, through experience or explanation, that “deep tissue” is a mode of performing a massage.  In fact, I understand “deep tissue massage” to be a technique of Swedish massage or a technique encompassed by another modality which indicates a level of superficial or profound system or musculature address.

The client misperception of the term “deep tissue” also indicates to me that the client is expecting a predetermined protocol and that they are willing and able to compromise their comfort level of receiving, risking tissue damage, to order what they perceive as a higher level of massage session.  Why would a professional set up an expectation for their client of “more pain(ful), more gain(ful)” in what is perceived as a predetermined and traditionally-accepted menu format?  For me, the depth and need for any specific level of pressure is always determined per client AND by session, and can vary greatly from health condition to season.

I have always been a proponent for a “one price massage”, removing what I believe is a misconception that the depth of a massage is more valuable the deeper it is.  Deeper does not necessarily mean “more therapeutic” – appropriate depth IS more therapeutic.  You could be an athlete that just ran a marathon: deep tissue is not appropriate up to 24 hours post-event.  You could be a cancer patient and deep tissue could NOT be appropriate only in certain areas or affecting certain systems.  You could be suffering from edema or lymphedema, whereby a diagnosis and working with the client’s doctor is more appropriate before applying deep strokes that can be damaging, or at the least, ineffective.

Ultimately. In my opinion, the client determines depth of stroke on a session-by-session, moment-by-moment, and stroke-by-stroke basis – and needs to be understood and applied immediately, appropriately, effectively, and compassionately – as to not do harm – by every massage therapist.

Take these thoughts and suggestions with you and see your massage become more productive – every time you get a deep tissue massage.

Comments

  1. Very helpful! I’m in the pain=gain camp of clients – and did have an incredible cure of my lifelong chronic headaches by a highly trained / skilled therapist. I think the pain was from some pressure point work rather than the massage, but I don’t specifically remember… And i did tell him, he reassured me and over the course of sessions i experienced a ‘miracle’ cure.

    So i remember the general pain=gain outcome. And incorrectly applied that to other massages/therapists.

    I found this article because today I’m expriencing aches after a massage by a friend, after a long break from massage and some bad shoulder ache/pain. I encouraged heavy touch because the pressure if touch feels better than the stiff shoulder pain in the moment. I didn’t understand why I was achy today… Like I lifted weights that were too heavy yesterday. Now I do!! Thanks

    So for you massage therapists out there, working with someone like me who may encourage heavy touch/pain and not tell you;

    – tell you’re clients the mechanics of muscle stretching – and that you want to stop the stretch before the tear happens. This article is the fits time I ever understood that. Duh!!! Seems obvious but you’re client might not know.

    – establish a “pain scale” , maybe you could cll it an “intensity scale” – if I’m asked “how is that pressure” to eliminate the good/bad idea – unless it’s BAD I’m going to say “fine”. If they say “tell me if it hurts” I likely won’t because minor pain in a massage doesn’t meet my idea of “hurt” since I have a fairly high pain threshold. Instead If the therapist said at the start, “as I work I need feedback on how you experience the pressure, on a scale of 1-5 let me know how deep/intense the pressure feels to you. Let me know at any point, and i may ask from time to time”

    That would sure help me communicate better without having to sound impolite, or feel im exaggerating my ‘pain’ or judging the massage as good/bad.

  2. Jenny, thanks so much for your thoughtful post – excellent “client point-of-view” response which I do appreciate!
    This is a really good point you bring up: your intensity level ratings will differ from others’ ratings – spot on. So it is really important for the massage therapist to be cognizant of each client’s rating scale.
    Additionally, there is a physiological point at which muscle fibers (starting with the microscopic level) will tear regardless of the client’s propensity for pain. This is most obvious with the splinting effect that the muscle (groups) will enact when the stretching/massaging of the muscle is “too much” and will occur outside of the mental capacity for pain of the client. There are also many factors that will allow tearing of the muscle fiber (to a comfortable, and even pleasurable result for the client) and, in some cases, “fast recovery”, as not to show mass bruising in an area of micro-tears. This possibility depends a lot on the physical (good) health of the client.
    I have worked with clients VERY deeply and had such a muscular range of motion that it was even a challenge for me; a challenge in that it is rare to address the depth of work needed on a client who is very flexible to begin with. Recognizing every client’s need(s) and addressing them effectively is the responsibility of every massage therapist…and taking the range of motion of the clients physiology to the limits of “no damage” – that usually does not involve excessive pain, but, in some rare cases may.
    Thanks again for your post!
    D

  3. I have bookmarked your site in my browser to check back whenever you update your blog with another useful post. Keep up the good work.

  4. Thank you very much for this – I’m very interested to try out these techniques for some of my more sensitive clients.

  5. James Mulvenna says:

    I had my first deep muscle massage today and I want it to be my last! I have had massage in five countries of different types, today was too painful! Painful during and after and after this type of massage seems very dangerous. I feel damaged and sore, I would not call it therapy! There may be a place for it with someone who really wants and benefits from it. But I think to much and to deep and much pain will do potential damage to Tissue.

  6. Melton Harrell says:

    I’m a gym rat/heavy lifter and I love deep tissue massages. I wonder how frequently would be too frequently?

  7. Hi Melton,
    Generally, I recognize the effects of a massage therapy session to last two to three days, so twice a week is the most-frequently that I would recommend massage. I believe there are always cases and clients where more often is considered acceptable – the cumulative, positive physiological effects of the massage will persist in a shorter timeline, like that of ‘every other day’ or even ‘every day’, but if you’re working out regularly, recovery [from massage] – like from working out, letting your muscles heal – is an important factor. Deep Tissue-type massages where ‘pain’ is experienced can actually be a sign of microscopic damage to the muscle cells, much like after a heavy weightlifting session, so I wouldn’t recommend those types of Deep Tissue massages every other day.

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