"Low Risk" Does Not Equal "No Risk"

An Overview of Reports of Adverse Events

By Ruth Werner
[Pathology Perspectives]

An adverse effect or an adverse event in massage therapy is a situation in which a problem arose or was made worse by massage.  We work in a profession that is widely recognized to be a safe intervention, with a low risk of such circumstances. However, “low-risk” is not the same as “no-risk,” and massage-caused injuries certainly occur. While this usually means mild soreness following a session, sometimes massage-related adverse events can be serious.

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,” page 44) 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.

Published Case Reports

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.

What I Learned

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.


Bone Injuries

What happened?

Structure injured

Who did the massage?


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)


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)


“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.


Blood Vessels, Then Other Organs

What happened?

Structure injured

Who did the massage?


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


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


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


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.”


Spinal Cord and Nerves


What happened?

Structure injured

Who did the massage?


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.




What happened?

Structure injured

Who did the massage?


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)


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)


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.