When I was in massage school, students and practitioners shared whispered stories detailing catastrophic massage-related injuries.
"He ruptured the abdominal aorta, and the client died right there on the table."
"They massaged the leg, and wham! a DVT broke loose and went to the lungs. The client didn't make it."
"She did pressure going down the legs, and her client got these awful varicose veins."
These anecdotes may or may not be grounded in reality. I know some are true; I have been a consultant or expert witness in litigations about similar injuries. But if they don't make it into the public record, they must stay in the realm of massage mythology. We teach endangerment sites (see "Take the Danger Out of Endangerment Sites") to enable massage therapists to avoid becoming part of one of these stories, but it's hard to base education on unsubstantiated claims and cautions.
The following tables provide a sampling of published case reports about massage therapy and adverse events. As a reminder, a case report is a description of an interaction between one patient and one practitioner. Its conclusions cannot be generalized to apply to a broad population, but these stories can help us learn more about our work.
The case reports discussed here were not written by massage therapists. Instead, they were written by physicians who treated patients after they had been injured. For the sake of space and sanity, I present just a small sampling here, organized by what types of tissues were damaged. However, the whole collection is available in the reference list.
In the process of gathering this information, I found out a few things.
First, massage therapy is usually safe. This is indicated in several ways: a paucity of case reports on adverse events, a plethora of massage therapy studies stating "no adverse events were reported," and our low malpractice insurance rates. And for a reality check: there are thousands more articles documenting massage therapy doing good than doing harm.
Second, several adverse events reported in the medical literature were precipitated by the use of massage machines (tools, chairs, etc.) or by people without appropriate training to provide massage. This points to the value of accurate and thorough education on this topic. Several of the case report authors point this out as well, which is heartening.
And finally, only a tiny portion of adverse events make it into the medical literature. A different tiny portion of them are pursued in malpractice lawsuits, and those are never made publicly available. There are many reasons for low reporting of massage-related injuries, but this doesn't make it acceptable to be careless.
Even though massage is by and large a safe modality, it is our responsibility to our clients and to our profession to keep it that way by knowing how to avoid accidentally causing injuries. Isn't it convenient then, that a webinar on this very topic is now available at www.abmp.com/ce. For more on endangerment site education, whether it is over-taught or under-taught, and the importance of critical thinking skills, please enjoy my video conversation with Whitney Lowe above.
Note: In the reports below, I included studies that are in English, and those for which I had access to the whole article. I excluded studies published in other languages. I also excluded any studies that referred to cardiac massage, or CPR, and those in which the term manual therapy described care other than massage therapy.
A 66-year-old man with osteoporosis had chronic low-back pain along with pain and numbness radiating down his legs. His doctors recommended surgery, but he preferred conservative treatment with massage 2-3 times per week. After a massage "was performed more violently than usual by a young masseur," the patient went to the emergency department. He had a new pedicle fracture, along with preexisting spondylolisthesis and several other structural problems. (Guo, Zhiping et al. 2012)
Vertebra
Massage therapist
The authors theorize that this unusual injury was at least partly related to inappropriate pressure to the spine while the lumbar area was in hyperextension. The patient underwent spinal surgery. He fully recovered without any pain or numbness in his back or legs.
A 48-year-old man was diagnosed with a C6-C7 fracture and dislocation caused by excessive hyperextension of the neck during a massage. (Abilash, Kak et al. 2017)
Vertebrae
"Traditional masseuse" who had frequently seen this client for back pain
This client had undiagnosed ankylosing spondylitis when he received massage. At the time of his X-rays, he had damage throughout his spine. This massage session induced permanent tetraplegia.
A 38-year-old woman had a sudden onset of stroke symptoms after receiving a 20-minute neck massage with a handheld electric massager. (Grant and Wang 2004)
Artery, then brain
Not clear; possibly the patient
The patient had an acute infarction in the right middle cerebral artery and dissection of the right internal carotid artery. While the cause of this injury appears to be an electric device, it shows that damage to the carotid artery is possible with pressure at the anterior or lateral neck.
A 20-year-old man received traditional Thai massage from a friend. Three days later, he went to the emergency department with bilateral leg numbness and weakness. (Vanichkulbodee, Issaragrisil, and Inboriboon 2019)
Artery, then spinal cord
Layperson
An MRI found spinal cord compression from C6-T2 due to a spinal epidural hematoma. It was surgically corrected. At the time of writing, the patient was in an inpatient rehabilitation program to help manage his lower extremity motor deficits.
A 59-year-old man with a history of aortic bypass surgery hurt his back while moving a refrigerator. His wife tried to relieve his pain by walking on his back. Later that day he had severe left loin pain radiating to the groin. At the hospital he was diagnosed with an embolus to the left kidney. (Mikhail et al. 1997)
Artery, then kidney
Spouse
The patient was prescribed anticoagulants and later underwent corrective surgery. He had a full recovery. The authors believe that occlusions had been building in the aorta over a long period of time, but that the massage precipitated dislodgement.
A 53-year-old woman received a "vigorous" calf massage from her pedicurist. It was so painful she asked them to stop. Soreness persisted on the left side for two weeks, followed by a sudden onset of shortness of breath. She was diagnosed with extensive acute pulmonary emboli. (Jabr 2007)
Vein, then lung
Pedicurist
This case demonstrates a possibility that massage didn't just loosen a preexisting clot, but did enough damage to cause a new clot to form. From the author: "In summary, massage of the lower extremities done by nonprofessional persons . . . is not free from risks."
A 43-year-old man with no history of symptoms received a cervical massage. He felt weakness during the session, which progressed to full paralysis. He was diagnosed with acute spinal cord pressure. (Cheong et al. 2012)
Spinal cord
Massage therapist with a private certificate at a massage center
It was found that this patient had ossification of his posterior longitudinal ligament and an acutely herniated nucleus pulposis between C5 and C6. He underwent extensive neck surgery to stabilize his vertebrae. Three years later he was still mildly impaired but able to live independently.
From the authors: "In our case, compressive myelopathy occurred after massage therapy induced tetraplegia and neuropathic pain."
A 40-year-old woman developed posterior interosseus nerve palsy following six sessions of friction massage for tennis elbow. (Wu, Hsu, and Wang 2010)
Posterior interosseus nerve (PIN)
Therapist at a clinic
The PIN is an extension of the radial nerve, responsible for wrist and finger extension. Friction massage to the lateral epicondyle muscle attachments was seen to temporarily damage the PIN. The patient regained full function two months after the end of friction treatments.
A 38-year-old woman received a single session of "deep-tissue massage." She had pain during the massage, which radiated down her left arm. (Aksoy et al. 2009)
Spinal accessory nerve
Massage therapist
Client pain persisted after the massage, in spite of NSAID use. She lost strength and range of motion. Two weeks later she was diagnosed with spinal accessory neuropathy. The spinal accessory nerve is accessible near the brachial plexus at the lateral neck. It supplies the trapezius and sternocleidomastoid muscles, and loss of function leads to shoulder weakness and scapular winging.
This person was treated with physical therapy that included exercise, heat, massage, and counseling on how to move without eliciting further injury. Two years after treatment, she had resolution of pain but strength and range of motion did not fully recover.
A 77-year-old man was diagnosed with rupture of a renal cyst and internal bleeding after "two vigorous massage chair sessions." (Mufarrij and Hitti 2011)
Kidney
Someone doing chair massage
This client had been diagnosed with polycystic kidney disease, which made his kidneys much larger than average. He also had coronary artery disease, hypertension, and pulmonary embolism. Among other medications, he was taking warfarin, a powerful anticoagulant—which probably contributed to his substantial retroperitoneal bleeding.
A 39-year-old woman with no diagnosed illness received "deep body massage" that included the abdomen. Within 24 hours, she developed abdominal pain. At 72 hours, she went to the emergency department. She had a large hematoma (bruise) of her liver and a low blood count. (Trotter 1999)
Liver
Unclear, but safe to assume person doing "deep body massage" in Denver in 1999 was a formally educated massage therapist
This client had no history of liver dysfunction or abdominal problems. After this massage, she received two units of packed red blood cells to make up for bleeding in her liver. She recovered fully.
Abilash, Kak et al. “Fracture-Dislocation at C6–C7 Level with Quadriplegia After Traditional Massage in a Patient with Ankylosing Spondylitis: A Case Report.” Malaysian Orthopaedic Journal 11, no. 2 (June 2017): 75–7. https://doi.org/10.5704/MOJ.1707.013.
Aksoy, Ibrahim A. et al. “Spinal Accessory Neuropathy Associated with Deep Tissue Massage: A Case Report.” Archives of Physical Medicine & Rehabilitation 90, no. 11 (November 2009): 1969–72. https://doi.org/10.1016/j.apmr.2009.06.015.
Behera, Chittaranjan et al. “Leg Massage by Mother Resulting in Fatal Pulmonary Thromboembolism.” Medico-Legal Journal 86, no. 3 (April 2017): 146–50. https://doi.org/10.1177/0025817217706645.
Chang, Chih-Ya et al. “Massage-Induced Brachial Plexus Injury.” Physical Therapy 95, no. 1 (January 2015): 109–16. https://doi.org/10.2522/ptj.20130487.
Chen, Hsin-Ling, Chin-Chu Wu, and Aming C.-M. Lin. “Small Bowel Intramural Hematoma Secondary to Abdominal Massage.” American Journal of Emergency Medicine 31, no. 4 (April 2013): 758.e3–758.e4. https://doi.org/10.1016/j.ajem.2012.11.020.
Cheong, Hyun S. et al. “Spinal Cord Injury Incurred by Neck Massage.” Annals of Rehabilitation Medicine 36, no. 5 (October 2012): 708–12. https://doi.org/10.5535/arm.2012.36.5.708.
Cho, Ju Y. et al. “Isolated Injury to the Tibial Division of Sciatic Nerve After Self-Massage of the Gluteal Muscle with Massage Ball.” Medicine 98, no. 19 (May 2019): 1–4. https://doi.org/10.1097/MD.0000000000015488.
Dutta, Guatam et al. “‘Crick’ in Neck Followed by Massage Led to Stroke: Uncommon Case of Vertebral Artery Dissection.” World Neurosurgery 115 (July 2018):41–3. https://doi.org/10.1016/j.wneu.2018.04.008.
Grant, Arthur C. and Norman Wang. “Carotid Dissection Associated with a Handheld Electric Massager.” Southern Medical Journal 97, no. 12 (December 2004): 1262–63. https://doi.org/10.1097/01.SMJ.0000145391.86504.CC.
Grant, Keith E. “Massage Safety: Injuries Reported in Medline Relating to the Practice of Therapeutic Massage—1965–2003.” Journal of Bodywork and Movement Therapies 7, no. 4 (October 2003): 207–12. https://doi.org/10.1016/S1360-8592(03)00043-3.
Guo, Zhiping et al. “Isolated Unilateral Vertebral Pedicle Fracture Caused by a Back Massage in an Elderly Patient: A Case Report and Literature Review.” European Journal of Orthopaedic Surgery and Traumatology 23, suppl. 2 (June 2012): 149–53. https://doi.org/10.1007/s00590-012-1031-y.
Hsu, Po-Cheng et al. “Acute Radial Neuropathy at the Spiral Groove Following Massage: A Case Presentation.” PM&R 9, no. 10 (October 2017): 1042–46. https://doi.org/10.1016/j.pmrj.2017.03.010.
Jabr, Fadi I. “Massive Pulmonary Emboli After Legs Massage.” American Journal of Physical Medicine & Rehabilitation 86, no. 8 (August 2007): 691. https://doi.org/10.1097/PHM.0b013e31811e2a7a.
Jeon, Chang-Hoon et al. “Case Report: Electrical Automated Massage Chair Use Can Induce Osteoporotic Vertebral Compression Fracture.” Osteoporosis International 30, no. 7 (April 2019): 1533–36. https://doi.org/10.1007/s00198-019-04961-4.
Kaur, Jaslovleen et al. “Frequent Neck Massage Leading to Bilateral Anterior Cerebral Artery Infarction.” BMJ Case Reports 2017. https://doi.org/10.1136/bcr-2017-222169.
Lee, Tzu-Han, Jan-Wei Chiu, and Rai-Chi Chan. “Cervical Cord Injury After Massage.” American Journal of Physical Medicine & Rehabilitation 90, no. 10 (October 2011): 856–59. https://doi.org/10.1097/PHM.0b013e318228c27c.
Lim, Danny C. G. et al. “Massaging the Outcome: An Unusual Presentation of Pulmonary Embolism.” BMJ Case Reports 2009. https://doi.org/10.1136/bcr.01.2009.1505.
Liu, J. S., T. C. Tsai, and Y. Y. Chang. “Extracranial Internal Carotid Artery Dissection Secondary to Neck Massage: Visualization of Mural Hematoma by MRI.” Kaohsiung Journal of Medical Sciences 9, no. 5 (May 1993): 322–27.
Mikhail, A. et al. “Renal Artery Embolization After Back Massage in a Patient with Aortic Occlusion.” Nephrology, Dialysis, Transplantation 12, no. 4 (April 1997): 797–98. https://doi.org/10.1093/ndt/12.4.797.
Mufarrij, Afif J. and Eveline Hitti. “Acute Cystic Rupture and Hemorrhagic Shock After a Vigorous Massage Chair Session in a Patient with Polycystic Kidney Disease.” American Journal of the Medical Sciences 342, no. 1 (July 2011): 76–8. https://doi.org/10.1097/MAJ.0b013e31821a50c5.
Posadzki, Paul and Edzard Ernst. “The Safety of Massage Therapy: An Update of a Systematic Review.” Focus on Alternative and Complementary Therapies 18, no. 1 (March 2013): 27–32. https://doi.org/10.1111/fct.12007.
Rahman, Muhammad. N., G. L. McAll, and Kok-Soon Chai. “Massage-Related Perforation of the Sigmoid Colon in Kelantan.” Medical Journal of Malaysia 42, no. 1 (March 1987): 56–7.
Ryu, Je I. et al. “Cervical Epidural Hematoma that Induced Sudden Paraparesis After Cervical Spine Massage: Case Report and Literature Review.” World Neurosurgery 112 (April 2018): 217–20. https://doi.org/10.1016/j.wneu.2018.01.178.
Tak, Sandeep, Shubhanjali Tak, and Alok Gupta. “Peripheral Embolisation After an Abdominal Massage.” BMJ Case Reports 2014. https://doi.org/10.1136/bcr-2013-200827.
Trotter, James F. “Hepatic Hematoma After Deep Tissue Massage.” New England Journal of Medicine 341, no. 26 (December 1999): 2019–20. https://doi.org/10.1056/NEJM199912233412616.
Vanichkulbodee, Alissara, Suwara Issaragrisil, and Pholaphat C. Inboriboon. “Massage-Induced Spinal Epidural Hematoma Presenting with Delayed Paraplegia.” American Journal of Emergency Medicine 37, no. 4 (April 2019): 797.e1–797.e4. https://doi.org/10.1016/j.ajem.2019.01.017.
Wu, Ya-Ying, Wei-Chih Hsu, and Han-Cheng Wang. “Posterior Interosseous Nerve Palsy as a Complication of Friction Massage in Tennis Elbow.” American Journal of Physical Medicine & Rehabilitation 89, no. 8 (August 2010): 668–71. https://doi.org/10.1097/PHM.0b013e3181c567af.
Yang, Si-Dong, Qiam Chen, and Wen-Yuan Ding. “Cauda Equina Syndrome Due to Vigorous Back Massage with Spinal Manipulation in a Patient with Pre-Existing Lumbar Disc Herniation: A Case Report and Literature Review.” American Journal of Physical Medicine & Rehabilitation 97, no. 4 (April 2018): e23–e26. https://doi.org/10.1097/PHM.0000000000000809.
Yin, Pin et al. “Adverse Events of Massage Therapy in Pain-Related Conditions: A Systematic Review.” Evidence-Based Complementary and Alternative Medicine 2014. https://doi.org/10.1155/2014/480956.
Clients who have had head injuries can most benefit when their massage therapist makes them feel safe.
It's important to know the slight differences between fainting (syncope), and feeling faint, dizzy, or lightheaded.
While manual therapies do not stop the progression of Alzheimer's disease or dementia, they can help improve the patient's quality of life.
