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Many clients enjoy the sensation of deep tissue massage. Yet some therapists shy away from incorporating this form of massage into their treatments, believing it to require the application of force greater than what they can deliver. Or they are anxious about how to apply pressure safely.
Deep Tissue Massage describes how to use 83 compressive and stretching techniques in ways that are safe and effective for you and your clients. The reference contains step-by-step guidelines and over 165 color photos, which will help you deliver comfortable and satisfying massages to your clients. The techniques are organized by the part of the body being massaged (trunk, lower limbs, and upper limbs) and by the positioning of the client (three-quarter lying, supine, prone, and seated). Once you have learned about the techniques, you will then learn about incorporating them into effective routines by moving the client from one position to the next. Discover those techniques and treatment positions that appeal to you, and discard those that you find less helpful. You will find many of these techniques easy to apply and will quickly be able to include them as part of your practice.
Deep Tissue Massage explains techniques for avoiding overuse of your hands by incorporating the forearms, fists, and elbows. Throughout the book Client Talk boxes present tips for effective dialogue between therapist and client to ensure expectations are met and the client’s limits for handling deep pressure are not exceeded. A photo gallery index provides a quick reference for treatment ideas or for checking technique.
Whether you are new to massage or a therapist with many years of experience, Deep Tissue Massage will be a great companion resource. Novices will love the easily accessible language and organization of this book, while veteran therapists will check technique and add variety to existing treatment routines. If used in a classroom setting, this book can stimulate debate and discussion about the proper use of deep tissue massage.
Part I Getting Started With Deep Tissue Massage Techniques
Chapter 1 Introduction to Deep Tissue Massage
What Are the Methods of Application?
How Do You Increase the Depth of Your Massage?
How Is Deep Tissue Massage Different From Sports Massage?
What Are the Effects of Deep Tissue Massage?
Benefits of Deep Tissue Massage
Where and When Should Deep Tissue Massage Be Done?
Closing Remarks
Quick Questions
Chapter 2 Preparing for Deep Tissue Massage
What Type of Massage Therapist Are You?
Establishing Your Intention
Using Your Body
Choosing Where to Use Forearms, Elbows, Fists and Squeezing
Using Your Equipment
Understanding Cautions and Safety Issues
Commonly Asked Questions and Concerns
Top Tips for Treating Clients
Tips for Working Safely With Deep Tissue Massage
Closing Remarks
Quick Questions
Part 2 Deep Tissue Massage Techniques
Chapter 3 Compressive Techniques
Introduction to Compressive Techniques
Forearms
Fists
Elbows
Squeezing
Tools
Closing Remarks
Quick Questions
Chapter 4 Stretching Techniques
Introduction to Stretching Techniques
Without Oil (Dry Stretching)
Dry Stretch
Traction
Dry Stretching for the Piriformis Muscle
‘With Oil’ Stretching
Stretching With Oil Plus a Passive Joint Movement
Stretching With Oil Plus an Active Joint Movement
Closing Remarks
Quick Questions
Part 3 Applying Deep Tissue Massage
Chapter 5 Deep Tissue Massage for the Trunk
Three-Quarter Lying
Supine
Prone
Seated
Quick Questions
Chapter 6 Deep Tissue Massage for the Lower Limbs
Three-Quarter Lying
Supine
Prone
Quick Questions
Chapter 7 Deep Tissue Massage for the Upper Limbs
Three-Quarter Lying
Supine
Prone
Quick Questions
Part 4 Deep Tissue Massage Routines and Programmes
Chapter 8 Creating Deep Tissue Massage Routines
Initial Questions
Tests
Notes Concerning Timing
Practice Routines
Case Studies
Closing Remarks
Jane Johnson, MSc, PhD, is a chartered physiotherapist and sport massage therapist specializing in occupational health and massage. In this role she spends much time assessing the posture of clients and examining whether work, sport, or recreational postures may be contributing to their symptoms. She devises postural correction plans that include both hands-on and hands-off techniques.
Johnson has taught continuing professional development (CPD) workshops for many organizations both in the UK and abroad. This experience has brought her into contact with thousands of therapists of all disciplines and informed her own practice. Johnson has a passion for inspiring and supporting students and newly qualified therapists to gain confidence in the use of assessment and treatment techniques.
Johnson is a member of the Chartered Society of Physiotherapy and is registered with the Health Professions Council. A member of the Medico Legal Association of Chartered Physiotherapists, she provides expert witness reports on cases involving soft tissue therapies. Johnson is the author of six titles in the Hands-On Guides for Therapists series. These are, Postural Assessment, Postural Correction, Therapeutic Stretching, Soft Tissue Release, Deep Tissue Massage and Soft Tissue and Trigger Point Release. Postural Assessment has sold over 10,000 copies. She is also the author of The Big Back Book: Tips & Tricks for Therapists.
Jane regularly delivers webinars on popular musculoskeletal topics, as well as on life working as a therapist. In her Facebook group (Jane Johnson The Friendly Physio), she shares tips and tricks in her usual, friendly manner.
Johnson lives in the north of England in an unmodernized house where she creates books and webinars, makes art and rehomes big rescue dogs.
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event
Guidelines for using your body during a deep tissue massage
You will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Using Your Body
Assuming you are in good health and feel rested and energized, there is little you need do differently to prepare yourself to apply deep tissue massage. However, you will be using your body in a way different from when you apply Swedish massage techniques, so you might find it useful to read through these guidelines relating to the use of forearms, fists and elbows.
Forearms
Using your forearms to massage means you need to get closer to your client, and it is tempting to flex at the waist to do this. You will be working with your treatment couch set at a fairly low height because this facilitates leverage. Prolonged unsupported flexion of the trunk strains the ligaments of the back, results in pain and could lead to problems later. Instead, when using your forearms, ensure you are either in a good, wide stance or that you are supporting yourself by resting your other arm on the treatment couch (or on the forearm you are using to massage). An alternative is to sit on the treatment couch, as in the example shown on page 97 under Using Your Forearm on Trapezius (With Arm Abducted). The disadvantage of sitting in this way is that you need to twist slightly at the waist to apply the stroke, and some therapists find this position uncomfortable.
Something else to consider when using your forearms is that pressure will be more concentrated to the glenohumeral joint of your own shoulder. When working statically, such as when applying compression (see, for example, p. 118, Using Your Forearm on Gluteals), this is not normally a problem. Problems occur when you start to apply forearm effleurage from a static position and do not move along the treatment couch. With the application of lighter massage this is fine, but with deeper pressure you start to both compress and move your own joint, grinding it as you pivot from the shoulder. The simple solution is to try to always move alongside the treatment couch as you effleurage, sustaining pressure through your glenohumeral joint yet minimizing its movement.
Fists
To make a fist we must flex the metacarpophalangeal joints that form the knuckles (where the hand meets the fingers) and the interphalangeal joints of the fingers (figure 2.1). When using your fists to apply strokes in deep tissue massage it is best to avoid applying pressure while these joints are unsupported. This prevents directing pressure through the joint in such a way that compromises its stability. Pressure is best directed through the bones of a joint when those bones are end to end, rather than angled with respect to each other. But to work with the bones of the hands and fingers end to end means you have your fingers straight, in the extended position, not in the shape of a fist. The most preferable way to use your fists safely is either to keep your fingers fairly loose, cup your hands together (e.g., the therapist's right fist on p. 112 under Fisting the Medial Calf) and press through the relatively flat surface provided by your metacarpals, or you can form a tight fist and press through your proximal interphalangeal joints, which should be firmly supported and unmovable in this position (e.g., p. 122, Fisting Hamstrings).
As with other joints, it is safer to keep your wrist joint in a neutral position when using fisting to apply deep tissue massage strokes. One reason therapists suffer overuse injuries is that they frequently apply constant pressure through an extended wrist joint. Wrist extension is, after all, inherent to the stroke of effleurage. Radial and ulnar deviations also occur in our wrists as we massage. Therapists risk injury to this joint when using repetitive rotary-type movements with pressure, such as when using fists to knuckle the upper trapezius. With light massage, overuse injuries of the wrist are not likely to be a problem, but as the pressure and frequency of your treatment increases you risk sustaining pain. You might also develop laxity in this joint if it is not protected.
Elbow
As when using your forearms, when using elbows it is necessary to lean onto the client, so you again need to guard your own posture to prevent injury to your back. In addition, remember that the ulnar nerve runs close to the surface of your elbow. If you experience pain, numbness or tingling in your arm when using your elbow, you might be compressing the ulnar nerve. You should stop using the technique or apply pressure with a different part of your elbow.
Deep tissue massage FAQ
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
Commonly Asked Questions and Concerns
Following are some commonly asked questions and concerns along with answers and ideas for solutions.
- I'm worried that when using my forearms, fists or elbows I will not be able to feel the client properly.
- It is true that you have fewer sensory receptors in the skin of your forearms, fists and elbows compared to your hands and fingertips. However, many of the techniques described in this book rely on compression. You can sense compression without using your fingertips because you have sensory mechanoreceptors in the joints of your wrist, elbow and shoulder that transmit information to the brain concerning pressure. When you compress a tissue, what you are sensing is the resistance to that pressure, and you can do this without using your hands.
- I'm using all of my force, but the client says it's still not strong enough.
- Deep tissue massage is not about force but technique. Read How Do You Increase the Depth of Your Massage? in chapter 1, page 7. Other possibilities are to lower your treatment couch, make sure you have adequate leverage, choose different techniques and, in some cases, use less oil. If all else fails, refer the client to another therapist.
- I'm concerned about the amount of pressure some clients demand. I can deliver this amount of pressure, but surely it's not good for them?
- Document your treatment outcomes and watch for negative side effects. If the client reports feeling fine and there is no bruising, you should be okay to continue. However, remember that if you are anxious during treatment, the client will sense this.
- I can never seem to get into the neck muscles properly. Is it safe to do deep tissue techniques to the neck?
- Not all techniques are safe for use on the neck. Refer to the section on anatomical considerations on pages 24-27.
- I'm worried I might hurt my client when using deep tissue techniques for the first time.
- It is good to be cautious. Follow the guidelines for the application of these techniques in chapters 3 and 4. Practice on friends, family and colleagues before using them on clients. Incorporate the new techniques gradually into your treatment.
- I'm concerned I'll cause bruising and the client will never come back.
- Bruising is rare when deep tissue massage is used on healthy clients who are not contraindicated for massage. Follow the safety guidelines for applying the techniques, and always combine deep tissue techniques with lighter strokes to help disperse blood and soothe tissues.
- Deep tissue techniques take longer to apply than Swedish massage. I want to use them but cannot extend the treatment time.
- This simply means you cannot apply all techniques all over the body in a single treatment. Be selective. Avoid the temptation to use the techniques at the same speed as you apply Swedish massage—this can cause pain and bruising.
- I have a fixed height treatment couch that cannot be lowered. Can I still use deep tissue techniques?
- Solutions are to change the couch, get onto the couch or do treatments on the floor or seated. You might find that you can apply some of the techniques, but not all of them; you might even discover new ways to get better leverage.
- I'm concerned that with all these extra techniques my massage treatments will feel disjointed.
- When you first trained in massage you might have focused on the application of one technique, practicing to get it right. Or you might have used several techniques but focused on one part of the body, such as the back or legs. Any skill takes time to acquire, and with practice you will learn to incorporate your favourite techniques into a regular massage routine.
- I'm not sure which of the techniques to use, and I wonder if clients will enjoy a deep tissue massage as much as a Swedish massage.
- A simple way to alleviate your concerns is for you to receive deep tissue massage yourself, perhaps from a colleague using the techniques described in this book. Judge for yourself, first, if you can tell if the therapist is using the palms or forearms to effleurage; second, judge which parts of the body different techniques feel best on.
Proper elbow techniques
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways.
Elbows
Elbows are commonly used as part of a deep tissue massage routine. They can be used in two ways. First, they can provide localized static pressure to relatively small muscles that require deep pressure (such as the tensor fascia latae or levator scapulae) or to a small, specific area of a large muscle (such as the origins of the hamstrings). Second, they can apply what is sometimes called stripping—that is, the slow, continuous application of pressure with oil along a narrow band of tissue.
Covering a smaller surface area, the pressure facilitated by the use of elbows is deeper than when using forearms or fists—and might even be as deep as when using a massage tool. For this reason, it is best to use elbows for deep pressure only after tissues are thoroughly warmed. (Of course all deep tissue techniques have a more profound effect and are safer to apply after tissues have been warmed using regular massage techniques.)
Using Your Elbows to Apply Static Compression
Use your hand to practice this technique on yourself before trying it on a client.
- Identify the spot you wish to treat and touch it with your elbow, keeping your elbow flexed (a).
- Extend your elbow slightly, while still touching the spot, but do not add any pressure yet (b).
- With your elbow on this same spot, still extended, lean onto the client (c).
- Maintaining the pressure, slowly flex your elbow (d).
- Ease up, reducing your pressure, and soothe the area.
- Repeat.
Using Your Elbows to Apply Stripping
To use your elbow to apply a stripping technique, follow these steps: Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Starting at the distal end of a thoroughly warmed muscle, identify the line of tissue along which you wish to strip (e.g., the centre of the calf muscle).
- Place your elbow at the distal end of this line, supporting your elbow with the web of your other hand.
- Lean onto your client with your elbow and, using the guide hand, slowly move from the distal end of the muscle to the proximal end.
- Soothe the area with strokes such as effleurage or petrissage.
- Repeat.
Safety Guidelines for the Use of Elbows
Additional safety guidelines for using the elbows relate to the fact that the pressure applied is so localized. When using the elbows, you must never compress main vascular structures, lymph nodes or nerves. You need to take extra care in controlling this technique. Be especially careful when using oil—you must guide your elbow to prevent it from slipping, keeping the elbow in the correct position on the muscle.
When using elbows to treat trigger spots, be sure to remove the pressure if the sensation of slight discomfort at the spot does not dissipate within 60 to 90 seconds. If the discomfort does not dissipate, this could indicate you are pressing into a spot other than a trigger spot.
Finally, remember that elbows should be used only after tissues have been thoroughly warmed. That said, with practice, many therapists become expert at applying just the right amount of pressure with the elbows, using this very pressure as part of the warm-up. Using elbows certainly facilitates the application of deep pressure, but such pressure doesn't have to be deep.
Advantages, Disadvantages and Uses of Elbows
After practicing compressive techniques using your elbows, tick the statements with which you agree in the following three lists:
Advantages
- Facilitates the application of very deep pressure
- Can be localized to a very specific spot
- Avoids strain on the therapist's wrist
- Easily links to compressive techniques using forearms
- Can be used with oil or as a dry technique
- Can be used through a towel or through clothing
Disadvantages
- Cannot be used on all muscles
- Can take time for therapists to learn to lean onto their clients when using elbows
When Is the Use of Elbows Indicated?
- When you need to apply very deep, localized pressure and do not have massage tools available and do not wish to use your fingers and thumbs
- For the treatment of trigger spots
- When your wrists and elbows are at risk of damage through overuse or if you are hypermobile in these joints
- When you wish to incorporate a compressive technique into a chair massage routine
- When you need to provide massage through clothing, such as at a sporting event