Minimizing Injuries

Some Common & Uncommon Advice

By Mark Liskey

As a 20-year-old experiencing back pain, I asked a chiropractor to tell me the one thing I could do to help me avoid back problems in the future. He said, “Move and work in a balanced way. For example, if you always turn to the left to reach for the shampoo in the shower, start turning to your right, too.”
I can’t say for sure to what extent taking his advice allowed me to maintain a decades-long massage career without being sidelined by back pain. However, I do know his advice made me more aware of my back while I was working. Therefore, I was less likely to put my back in compromising positions.
Now, as a massage therapist for 20-plus years and an educator for 10, I’ve observed many massage therapists teetering on the verge of injury because of poor form and/or decision making. In response, I’ve developed a list of some common and not-so-common suggestions to avoid massage injuries.

Got Glucose?
Could your blood sugar affect the quality of your work? Some say it does.
According to journalist John Tierney in The New York Times Magazine, when researchers analyzed more than 1,100 parole decisions at an Israeli prison, they found prisoners were granted parole a third of the time. Curiously, the parole approval rate fluctuated wildly during the course of the day.1
Early in the morning, parole was granted 70 percent of the time. By lunchtime, parole approval dropped to 10 percent. And after lunch, it was back up to 60 percent. This meant prisoners who committed identical crimes and had identical sentences had different parole outcomes based on the time of day the parole case was heard.
Studies since have elucidated the reason: low blood sugar.
“Your brain does not stop working when glucose is low,” Tierney writes. “It stops doing some things and starts doing others. It responds more strongly to immediate rewards and pays less attention to long-term prospects.”
Let’s apply this to the 2:30 p.m. massage. Here are the things I experience a couple hours after lunch: apathy, fatigue, and irritability. In an unconscious attempt to conserve energy (immediate reward), my feet stop moving and I start reaching and leaning farther than I normally do, putting my shoulders in compromising positions. I make poor decisions for my body in the massage room.
The good news is there is an easy solution to the afternoon low: eat an apple.
For six months, I ran my own little glucose experiment in the massage room. By counting calories, and adding low-fat, complex carbohydrate foods at the time of day I would normally be low in glucose, I was able to circumvent the low. I had steady energy with no real dips, even when I had less sleep than normal.  
The next time you feel off during a massage, check the time of the day and your food intake. When you’re fueled up, you’ll provide a better massage and avoid a potential injury because of a low-glucose-induced lapse in judgment.

Become Ambidextrous
Pitching in baseball is a one-sided activity. For many massage therapists, so is doing massage. Unfortunately, one-sidedness can lead to repetitive stress injuries.
Early in my massage career, I aggravated an old injury in my right shoulder—my dominant arm. Though severely one-sided at the time, I was forced to use my left arm.  
It was an awkward start, but after getting some reps in with my left arm, I was able to rest my right arm during the massage. Eventually, I became comfortable using my left arm almost as much as my right. So, whenever my right shoulder would act up, I’d transfer more of the workload to my left arm for a week or so until my right shoulder recovered.
In retrospect, forced adaptation, though effective, may not be the ideal way to become ambidextrous. A sudden and steady workload increase to a joint is risky business.
A safe way to become ambidextrous is to start slowly and be strategic. By strategic I mean don’t test your first, second, or third attempt of nondominant-arm massage strokes on a paying customer. You need to work through the beginner phase on massage volunteers—colleagues, family, friends, etc. When you feel your nondominant arm can deliver close to the same static (not moving) pressure as your dominant arm, try it out on a paying customer, but for a short time. As you get better, slowly increase the time and variation of your massage strokes.
Also, experiment with becoming ambidextrous outside of work. For example, use your nondominant hand for operating a mouse, brushing your teeth, or eating. Of course you may want to practice eating with your nondominant hand at home first!

Use All The Tools In Your Kit
Staying with the baseball analogy, if you become ambidextrous, you can start to pitch the game with your left arm and finish the game with your right. You’re potentially avoiding one-sided injuries. But in our line of work, repetitive stress injuries can happen to both sides at once. For example, say you’re doing a lot of specific work with your thumbs and they both start to hurt. What do you do?  
Use your knuckles. Or your elbows!
Massage therapists, unlike pitchers and assembly-line workers, have the option to utilize different tools to get the job done. Here are the tools we can choose from: elbows, fingers, forearms, knuckles, palms, and thumbs. The trick is to be able to deliver the full range of pressures—deep, light, and medium—with each tool in order to have the most tool options.  
To do this, we first need to rate the tools on their capacity to transmit pressure. For example, it’s easier to apply deep pressure with an elbow than it is with a thumb. My rating scale, from least to greatest capacity to transmit pressure, looks like this: palms, fingers, thumbs, knuckles, and forearms/elbows.  
Notice thumbs are in the middle of the scale. They are good at delivering both light and deep pressure. It’s not surprising we often wear them out.
Imagine resting your thumbs by using your knuckles. Here’s how you can start. Place your thumb on the spinal erectors of one side of the back around T12. Apply light pressure. Next, make a fist, allowing the middle knuckle to extend out a quarter to a half inch away from the other knuckles. Place the knuckle where you had the thumb. Apply light, medium, and deep pressure again. Though awkward at first, you should begin to feel that it’s easier to generate deeper pressure with your knuckle than it is with your thumb. With a little practice, you will feel comfortable with your knuckle at all pressure ranges.
After you master the tools with various pressures, you just have to pick the best tool for the job. For example, if the client wants deep pressure in her lower back, choose the tools that are better for delivering deeper pressure—elbows and knuckles. Save your thumbs for deep-pressure spots that are difficult to get to with bigger tools, such as cervical erectors.  
Finally, when you use a smaller tool like a thumb for deeper pressure, brace it when you can. For example, two thumbs side-by-side provide a more stable framework for applying pressure than one thumb. A thumb next to a knuckle or a finger on top of a finger distributes the exertion of pressure over two tools instead of one. Practice bracing in this way, and it won’t be long before using two tools braced together will feel more natural than using one.

Learn to Lean
Joe, a massage therapist, was a tall and solidly built man. When I was training him to do on-site massage, I thought he would have no problem delivering deep pressure. But when I was on the table, his work was woefully below the pressure level I knew some clients would want.  
Prior to Joe, I had trained Karen on how to deliver deep pressure. Karen was thin and petite, but prided herself on making college football players say, “Yeah, OK, that’s enough pressure.”
The difference between Karen and Joe? Karen knew how to lean.
It has been my experience that leaning—using your body weight for leverage—to deliver deep pressure will tax your musculoskeletal system less than nonleaning stances. In some cases, it’s nearly impossible to generate the required pressure without leaning.  
Anyone can learn how to lean to generate pressure. The keys for safe and effective leaning are: lean into the table with your whole body; not just from the waist up, keep your joints in a straight line (e.g., shoulder over elbow when using your elbow/forearm); and move your feet when gliding so your joints stay in a straight line.

Find Your Max
Plain and simple, there is a limit to how many massages you can do before something breaks. The way most massage therapists find their maximum threshold is by going over it and dealing with the ramifications: pain and potential loss of income.
If you are just starting your massage career, your maximum tolerance will increase as your body gets used to doing massage on a daily basis. Some signs that indicate you are at your physical max are when your normal body pain is more persistent or intensifying, or when there is new pain.
If you have physical pain from doing massage, maybe it’s fixable by addressing a perpetuating factor, such as adjusting a massage table that is too low or too high. If the pain goes away after you make the adjustment, you’re probably not at your max and you can push your number of massages per week higher if you need to. If the pain doesn’t go away after addressing perpetuating factors, you’ve hit your ceiling. 

Take Recovery Time
Marty Hoffman, MD, is an ultra-marathoner. Several years ago, I interviewed him for an article about whether a runner should run through pain—for example, a sore hamstring.2
“If your goal is to finish the race,” he said, “why not go for it—as long as you allow time for recovery after the race.”  
You may be thinking, “I’m not planning on running 50-plus miles in the near future,” but you may have other races to run, like deciding you need to take an extra massage job in order to afford a vacation this year. And like a runner pushing through those extra miles, you’ll have to seriously tax your body to get the job done.
You’ll need recovery time.  
Here’s a suggestion: consider two or three lighter weeks of massage after you wrap up the extra massage job. You can make up the lost income from the lighter weeks by spreading it out over the rest of the year.
Plan for active recovery time while working the extra massage job by taking advantage of the things you can control in your work schedule—namely, scheduling your personal clients. For example, if you know you get slammed at your extra massage job on Wednesdays, schedule fewer private clients (and/or schedule clients who are less physically taxing) on Thursday to give your body a break. Or schedule them for Friday or Saturday instead. You’re still working, meeting their needs, and paying your bills.
Experiment with recovery time. Does your body respond better after doing a long day of massage followed by a day of no massages? Or does your body prefer consecutive days of shorter hours, followed by a rest day?  

Lower Your Max Over Time
There was a time in Major League Baseball when sluggers in their golden years hit more home runs in a season than they did in their prime. Unfortunately, they were using performance-enhancing drugs. Barring that option, we are left to strategize.  
Ask yourself these questions: in five, 10, 15, or 20 years, how many massages do I want to do per week? If your per-week goal at the 20-year mark is higher than your per-week goal at five years, you may want to consider this: 20 years from now, you’ll be more susceptible to injury due to injury compensation, reaggravation of old injuries, and slower recovery times.
That’s not to say that massage is only a five-year career. It can be a lifetime endeavor. However, it’s unrealistic to think that the same workload can be maintained as one ages. Plan your financial future so that if you want to lower your max someday with less hands-on work, you can.
Here are some massage-related jobs to consider: personal trainer, wellness coach, massage business manager/front desk staff, massage business owner, massage instructor, massage association professional, massage retail sales—and, of course, massage writer.  

Keep it Going
Just like a professional athlete, you’re going to get aches and pains while playing the game. But an ache doesn’t have to turn into a career-ending injury if you follow the points outlined here.
Lastly, consider short-term disability insurance for those times injuries occur despite our best planning. Associated Bodywork & Massage Professionals members can get discounts with I-surance ( Then, you’ll have all bases covered so you can enjoy a long and rewarding career.

1. John Tierney, “Do You Suffer From Decision Fatigue?” The New York Times Magazine, August 17, 2011.
2. Mark Liskey, “Running with Pain—Breaking the Rules,” accessed January 2015,

Mark Liskey is a massage therapist specializing in neuromuscular massage. He is a CE provider and co-owner of PressurePerfect (, a massage company that practices the tenets of conscious capitalism. He can be reached at