Take the Danger Out of Endangerment Sites

Good Education and Skill Allows for Safe Massage in Otherwise Off-Limits Areas

By Ruth Werner

Every now and then I am called upon to act as a consultant or expert witness in litigation cases where a massage therapist might have injured a client. My work in this arena has made it glaringly apparent that our profession lacks a comprehensive list of body areas where massage therapy must be conducted with extra care and expertise, with rationales for why or what adjustments might be necessary. This article is offered as a remedy for this situation.


The topic of endangerment sites leans heavily on our profession’s oral traditions about safety. What I learned about endangerments comes from what my teachers learned, which came from their teachers’ teachers, ad infinitum. As such, we don’t have a deep evidence base on which to build this important information.

It isn’t possible to conduct clinical trials to validate or disprove endangerment sites, but we can look to the medical literature for case reports that link massage therapy to client injuries. This represents only a tiny portion of all instances of course, but it may help us prioritize our understanding of potentially vulnerable areas. An overview on the published research about client endangerments can be found in my Pathology Perspectives column in this issue on page 30.

In addition to published research, I drew input from the Entry Level Analysis Project (ELAP) and the Massage Therapy Body of Knowledge. Then I harassed and harangued several core curriculum educators and continuing education providers to look over the final list for their input. My thanks go out to all my colleagues who were so patient and generous.


What is an Endangerment Site?

Endangerment (or cautionary) sites are places where careless massage could damage some of the body’s most delicate tissues. This article provides a list of widely recognized cautionary sites, with some important caveats: inappropriate and insensitive pressure can damage any kind of tissue—not just especially delicate ones.

This article provides a list of widely recognized cautionary sites, with some important caveats. First, inappropriate or insensitive pressure can damage any kind of tissue—not just especially delicate ones. Also, this discussion pertains specifically to clients who are not pregnant. Much more stringent cautions must be observed for clients who are pregnant, as they are vulnerable to injuries that nonpregnant people don’t have to considers. And lastly, many potential cautions are related to dysfunctional organs and other tissues.

Good education and skill can allow us to work safely in areas that would otherwise be “off limits” to inexperienced practitioners. For instance, important work can be done in the axillary area, if we know how to avoid the brachial plexus and other vulnerable structures.

Generally speaking, we avoid causing injury to endangerment sites by using broad, flat, and often light pressure in these areas—as opposed to more intrusive work that may injure or irritate delicate tissues. Identifying an area as an endangerment or cautionary site doesn’t mean it can’t be touched; it just has to be touched and incorporated into the massage with special care. We can classify cautionary sites by tissue type or by location.


Bony Prominences

Bony prominences include the floating ribs, the xiphoid process, and others. Under typical circumstances, massage over bony prominences poses no particular risks. However, vigorous or forceful massage over the spine or other protuberances has been seen to cause injury, especially if some other bone-related compromise (e.g., osteoporosis, ankylosing spondylitis, cancer metastasis, or bone thinning due to medications) is present.


Nerves include the brachial plexus, the sciatic nerve, and others. Nerves are identified as endangerment sites in areas where they are easily pinned onto other tissues—especially underlying bones. They are less at risk when they are surrounded by thick layers of soft tissues.

Pinning, stretching, or compressing nerves can bruise, irritate, or otherwise damage them. This may elicit sharp shooting, tingling, electric, or hot sensations. It is important to know the pathways of the most vulnerable nerves because, unfortunately, we cannot always count on clients—some of whom expect massage to hurt—to give accurate feedback about whether what they are feeling is “good” pain or “bad” pain.

Another issue to bear in mind about nerves is that they can become subtly inflamed along their entire length. In other words, if the median nerve is compressed at the carpal tunnel, then it may also be irritated at the antecubital fossa, and at the posterior triangle of the neck.

Blood Vessels

Blood vessels include the common carotid artery, the great saphenous vein, and others. Arteries generally run deeper than veins, and are less vulnerable to injury. However, anywhere a pulse can be taken, an artery can be compressed, and sustained pressure must be avoided.

The general risk of arterial entrapment is the blocking of circulation. Too much pressure can cause reduced sensation, discomfort, or even blackouts if applied at the carotid artery. Irritation of veins, since they are more delicate and tend to run more superficially than arteries, may cause varicosities, hemorrhages, or blood clots that lead to pulmonary emboli. Medical literature records many such events.

Massage therapy education promotes a common wisdom that we must always exert pressure from distal to proximal on the extremities in order not to damage veins. This may be an overstated concern for healthy clients, particularly in the arms. However, for clients who are pregnant, a variety of physiologic changes increases their risk for deep vein thrombosis, so massage and bodywork for the medial leg and inguinal area must be modified to minimize this risk. In other words, use broad, light pressure, rather than specific intrusive pressure in these areas.


Organs include the eyes, liver, kidneys, ovaries, and others, which can be trapped and impaired by massage therapy, especially if they are close to the surface or if they are anchored in a way that makes them vulnerable to being pinned or compressed.

Organs are especially at risk for damage if they are compromised by disorders. The scarring and inflammation of endometriosis may displace the uterus and ovaries, for instance. The spleen ordinarily isn’t accessible, but if it is enlarged as a consequence of mononucleosis or liver disease, it could be damaged with careless abdominal massage.

Many conditions can cause the liver to become enlarged and be palpable outside its normal boundaries. And while massage usually helps to resolve constipation, if the bowels are impacted, then intrusive pressure here may cause injuries.

Lymph Nodes

Lymph nodes include the cervical, axillary, and inguinal nodes, among others, and may be palpable when they are enlarged—which indicates the risk of infection and immune system activation. If lymph nodes are healthy, then they are typically not palpable with massage.


Head and Face


Structures of Note

• Trigeminal nerve branches

• Facial nerve

• Styloid process of the temporal bone

• Cervical lymph nodes

• Greater occipital nerves


Obviously, eyes are a local caution for massage, and special care must be taken with clients who wear contact lenses, who may prefer not to lie prone. Some practitioners keep a bottle of distilled water and a clean lens case available in case clients might want to remove their contacts.

Trigeminal Nerve Branches

Three pairs of foramina allow the mental (from the chin), infraorbital (from the cheek), and supraorbital (from the forehead) branches of the trigeminal nerve to exit from the skull to provide sensation for the face. Heavy pressure on these spots can elicit unnecessary pain, and may even bruise the nerves as they emerge (Image 1).

Retromandibular Fossa

If you put your index finger behind your earlobe, and press gently anteriorly, you will find the retromandibular fossa where the facial nerve exits. This area is close to the mastoid process where the sternocleidomastoid attaches, so it is not unusual for massage therapists to work in this neighborhood. But if our pressure strays, we are close enough to the facial nerve to cause a problem.

The styloid processes of the temporal bone are located medial to the mastoid process. It is extremely unlikely that a massage therapist would encounter these very sharp, fang-like bony prominences, but sometimes they grow extra-long or the ligaments that attach to them become injured, so it’s useful to have the styloid processes of the temporal bone on our radar (Image 2).

Occipital Ridge

The left and right greater occipital nerves (the occipital ridge) emerge from the deep fascia of the posterior neck, about an inch lateral to the spinous process of C2. Transient pressure at this site is unlikely to damage the nerves, but headache symptoms can occur if pressure is sustained (Image 6).



Anterior Neck


The anterior triangle of the neck is defined by the medial edge of the sternocleidomastoid muscle and the midline of the neck. Valuable work can be done in the anterior triangle of the neck to assist with muscles involved in swallowing, speech, and breathing. However, many structures are vulnerable to damage here, and advanced education is necessary to work safely in this area. Medical literature shows many cases where inappropriate massage has caused damage to anterior neck structures, with potentially catastrophic consequences for clients (Image 3).


Structures of Note

• Common carotid artery

• Jugular vein

• Hyoid bone

• Thyroid cartilage

• Trachea

• Thyroid gland

• Cervical lymph nodes

• Esophagus

Common Carotid Artery

This huge artery runs just deep to and alongside the medial sternocleidomastoid muscle, carrying blood upward to the brain. Downward (superior-to-inferior) pressure on or near the carotid artery may cause shearing of the arterial walls and a risk of blood clots and stroke.

About level with the thyroid cartilage, the carotid artery splits into internal and external branches. This point of division, called the carotid sinus, is equipped with nerves that track blood pressure to ensure that adequate blood flow to the brain is always maintained. Manual pressure applied at the carotid sinus can interfere with this function, leading to dizziness and faintness.

Atherosclerotic plaque is common in the carotid artery, which makes this area a special caution for any client with a history of, or risk for, cardiovascular disease.

Jugular Vein

The jugular vein also runs alongside the sternocleidomastoid muscle. Compression to this vessel is less likely to have a negative outcome, but it still should not be manipulated. The external branch of the jugular vein is also accessible as it crosses over the sternocleidomastoid.

Hyoid Bone

The delicate U-shaped hyoid bone is attached to the thyroid cartilage, just inferior to the mandible, and it moves with swallowing and vocalization. The hyoid bone anchors muscles of the tongue and neck that are associated with speech and swallowing.

Thyroid Cartilage

The thyroid cartilage or “Adam’s apple” is a moveable piece of connective tissue that forms the anterior wall of the larynx. It bobs up and down as we modulate our voice and swallow. This cartilage is strong but compression here can elicit pain and a choking sensation.


This tube is part of the respiratory system that carries air to the lungs. It is tough and resilient, composed of cartilaginous rings that keep the airway open. Pressure here causes an unpleasant choking sensation.

Thyroid Gland

The thyroid gland (which has nothing to do with the thyroid cartilage) is a butterfly-shaped organ that wraps around the trachea. It is an endocrine gland, secreting hormones that help control metabolism and calcium levels in the blood and bones. The tiny parathyroid glands are embedded within the thyroid. This whole structure is mostly made of delicate epithelial tissue, with little connective tissue protection.

The thyroid gland may become enlarged for various reasons; this is called goiter, and may be clearly visible in some people. The thyroid gland may also develop single or multiple cysts or nodules.

Very early studies in animals and humans suggest that manipulation of the thyroid may stimulate hormone release. This is flatly outside our scope of practice—massage therapists should not be trying to alter hormone secretion through manipulation of the thyroid gland.

Cervical Lymph Nodes

About 300 lymph nodes are located in the neck, in the posterior triangle, the anterior triangle, and under the mandible. Under normal circumstances lymph nodes do not require special adaptations in bodywork, but when they are hardened, enlarged, or painful for any reason they should be at least locally avoided.


The esophagus runs from the pharynx to the stomach. It is on the posterior side of the larynx and trachea, so it is seldom vulnerable to damage from massage—unless the practitioner is working deeply in the anterior triangle of the neck.



Lateral Neck


The posterior triangle of the neck, defined by the lateral sternocleidomastoid, medial trapezius, and middle one third of the clavicle, is not actually on the posterior aspect of the body. Rather, this label refers to the area between the lateral sternocleidomastoid, the medial trapezius, and the middle third of the clavicle (Image 4).


Structures of Note

• External jugular vein

• Transverse processes of cervical vertebrae

• Roots of brachial plexus

• Spinal accessory nerve

External Jugular Vein

The external jugular vein crosses over the sternocleidomastoid. This is also shown clearly in Image 2. This is important, because lots of massage techniques involve some specific handling of this muscle—and remember the internal jugular vein and carotid artery are close by as well.

Transverse Processes of the Cervical Vertebrae

A lot of helpful massage can be done in the posterior triangle of the neck, especially as we seek to access the scalene muscles that are often involved in neck and upper back pain. However, we need to be aware that the transverse processes of the vertebrae can feel sharp and pointy. It is not helpful to impale the scalenes on these bony prominences.

Roots of Brachial Plexus

The roots of the brachial plexus emerge from the intervertebral foramina between C5 and T1, and these nerve roots are substantial—the size of shoelaces, in some people. Any pressure here that elicits tingling, numbness, shooting pain, or other neurological signs needs to be changed immediately.

Spinal Accessory Nerve

The spinal accessory nerve supplies motor control to the sternocleidomastoid and the trapezius. It is vulnerable in the posterior triangle of the neck, where damage can lead to long-term weakness in the nearby muscles.




Structures of Note

• Brachial plexus

• Cephalic vein

• Subclavian vein

• Subclavian artery

• Breast tissue

Brachial Plexus, Cephalic Vein, Subclavian Vein

Just below the clavicle, where the lateral part of the pectoralis major and the anterior portion of the deltoid meet, there’s a groove where the brachial plexus nerves and the blood vessels of the upper arm pass through. The pectoralis minor muscle, which is often involved in neck and upper back pain, can be accessed in this area, but these nearby structures are mostly unprotected. It is important to be careful to work in this area with a broad, flat surface rather than with sharp, pointy fingertips (Image 4).

Breast Tissue

Breast tissue can be tender and uncomfortable when manipulated carelessly. Both male and female clients may need care to work around this delicate tissue.

If you have special education in breast massage, and if your local legislation allows it (and if your client gives consent), then this modality can be a helpful intervention, especially in situations involving fluid congestion and lymphatic flow.


Abdomen & Upper Extremity


The abdomen is often an under-addressed area in typical relaxation massage, and that’s a pity. It is important to incorporate this part of the body into massage, for many reasons. That said, several structures can be accessed here, and they are vulnerable to damage, especially if they are inflamed, enlarged, or not functioning normally (Image 5).


Structures of Note

• Xiphoid process

• Floating ribs

• Liver and gallbladder

• Spleen

• Small and large intestines

• Ovaries, uterus

• Abdominal aorta

• Vena cava

Xiphoid Process

The xiphoid process can be broken if sharp, downward pressure is exerted on it. This can cause damage to the liver, which is right underneath.

Floating Ribs

Massage is unlikely to damage floating ribs, but tracing or outlining the rib cage can cause ticklishness or even pain if a therapist does not know exactly where the floating ribs are and how to avoid pinning soft tissue against them.

Liver and Gallbladder

A massage therapist would have to be working much too deep and hard than is usually called for to bruise a healthy liver. However, clients with enlarged livers due to hepatitis, jaundice, cirrhosis, or other problems (such as an inflamed gallbladder) may be particularly sensitive in this area.


The spleen is tucked up way under the left ribs. For most people, the spleen is not a significant endangerment, but if it is enlarged for any reason (for instance as a person is recovering from mononucleosis) the whole area can be uncomfortable.

Small Intestines and Colon

While massage therapy is generally helpful for constipation, if a person has any kind of impaction or structural damage to the intestines, then intrusive work here risks damaging these structures. Whether effleurage in a counterclockwise direction over the abdomen can actually cause reverse peristalsis is highly debatable, but clockwise effleurage appears to be soothing for most clients.

Ovaries and Uterus

The ovaries and uterus of a person who is not pregnant and who has no history of inflammation or scarring in the pelvis are normally located so low and central that they are inaccessible to massage therapists. But pregnancy, ovarian cysts, endometriosis, pelvic surgery, infection, or other situations can cause disruption in the pelvic cavity, making the uterus and ovaries susceptible to being pinned or bruised with intrusive abdominal work.

Abdominal Aorta

This major artery of the abdomen is not typically visible or palpable. However, if the therapist observes a prominent throb (the abdomen can be seen obviously and substantially pulsating), then it is best not to do compressive work, and to recommend that the client consult their primary care physician about their cardiovascular health. If no visible pulse is present, but it is palpable with pressure, then withdraw and replace to avoid compressing the aorta.

Vena Cava

The vein that drains the lower half of the body is carried deep in the abdomen and is not typically palpable. However, the weight of a late-term fetus can compress it, leading to muscle cramping or faintness. This is one reason it is important for well-advanced pregnant clients not to lie supine.


Posterior Trunk


Structures of Note

• Occipital nerves

• Kidneys

• Spinous processes of the vertebrae


The kidneys are vulnerable to damage because they are only partially protected by the rib cage. The right kidney sits a bit lower than the left. Traditionally we learn that the kidneys might be bruised with tapotement in this area. Such tapotement would have to be very aggressive indeed, because several layers of muscle and fascia lie between the kidneys and the skin, but the musculature in the low back is highly reactive, and sudden or intrusive pressure here may stimulate a reflexive contraction (Image 6).

Spinous Processes

Spinous processes are listed as endangerments because massage therapists can cause pain by pressing paraspinal muscles in toward the spinous processes, rather than out and away from them. Pressure toward the spine can be appropriate, as long as soft tissues are not being impaled or ground into hard ones.



Upper Extremity


Structures of Note

• Brachial plexus nerves at numerous sites

• Axillary lymph nodes

• Axillary artery

• Axillary vein

• Radial nerve at posterior humerus

• Cephalic vein

• Brachial artery

• Brachial vein

• Median cubital vein

• Median and radial nerves at antecubital fossa

• Ulnar nerve at cubital tunnel

• Median nerve at carpal tunnel


The axilla is defined by the pectoralis major on the front, and the latissimus dorsi on the back. It houses the brachial plexus, lymph nodes, and blood vessels (Image 4).

Radial Nerve

The radial nerve wraps around the posterior humerus on its way from the axilla to the posterior side of the forearm. It is vulnerable to irritation when massage therapists work specifically on the triceps muscle. (Image 6).

Cephalic and Basilic Veins

Veins run in pathways that are unique from one person to the next, so it is impossible to state categorically where they might be vulnerable. One thing that is consistent, however, is that they run at least part way up the medial side of the upper arm. Conveniently, this is already an area to avoid because some of the brachial plexus nerves are also vulnerable here. The cephalic vein can also be trapped where it runs along the edges of the anterior deltoid and pectoralis major (Image 4).

Brachial Plexus Nerves

The musculocutaneous, median, and ulnar nerves run down the humerus, mostly on the medial aspect. The radial nerve detours to the posterior side. (Images 4 and 6).

Antecubital Fossa

The antecubital fossa (bordered by the epicondylar line of the humerus, brachioradialis, and pronator teres) or “elbow pit” houses the blood vessels that connect the upper to lower arm, along with the median nerve and a portion of the radial nerve (Image 5).                            

Cubital Tunnel

The ulnar nerve is vulnerable in the cubital tunnel, which is a groove between the olecranon and the medial epicondyle of the humerus. The familiar sensation of irritation here is what we call the “funny bone” (Image 7).         

Carpal Tunnel

The carpal tunnel is not generally considered an endangerment site. But, if the median nerve is irritated, then pressure here could elicit symptoms in the hand (Image 5).



Lower Extremity


Structures of Note

• Femoral nerve

• Femoral artery

• Femoral vein

• Inguinal lymph nodes

• Sciatic nerve

• Popliteal artery

• Popliteal vein

• Tibial nerve at popliteal fossa and tarsal tunnel

• Common fibular nerve at popliteal fossa, distal to head of fibula

• Small saphenous vein

• Great saphenous vein

Femoral Triangle

The femoral triangle, bordered by the inguinal ligament, medial sartorius, and adductor longus, is a particularly rich area for vulnerable structures. The femoral artery and vein are both accessible here, as are the inguinal lymph nodes and the femoral nerve. Deep, specific work on the adductors must be conducted with special care to avoid damaging these structures (Image 5).

Sciatic Notch

The sciatic notch is located deep to the deep lateral rotators. To access it manually would require pressing in deeply and intimately in the medial buttocks—typically not an area where most massage therapists work. The sciatic nerve, about as thick as a thumb where it emerges from the lumbosacral plexus, runs through the sciatic notch, into the deep lateral rotators (sometimes bifurcating the piriformis), and down the back of the leg, where it splits into the common peroneal nerve and the tibial nerve.

The sciatic nerve is difficult to pin or damage because the musculature surrounding it is so thick, but if the nerve is irritated for any reason it can become inflamed along its entire length, and careless massage may exacerbate the situation (Image 6).

Popliteal Fossa

The popliteal fossa (defined by hamstrings superiorly and the gastrocnemius and plantaris inferiorly) or “knee pit” holds several structures, including the small saphenous vein where it joins to the popliteal vein, the popliteal artery, and the lower extensions of the sciatic nerve: the tibial and common fibular nerves (Image 8).

Great Saphenous Vein

The great saphenous vein runs up the medial side of the calf where there is little to protect it from being pinned to the tibia. On the upper leg, the vein runs over the quadriceps along the edge of the sartorius. This area is bulky enough that pinning the great saphenous to the femur is not generally possible.

The great saphenous vein is the most likely location for varicosities to develop. If the skin is healthy, then light, broad, flat pressure here moving distally to proximally can be appropriate. Anything more challenging than that may not be a good idea (Image 9).

Tarsal Tunnel

The tarsal tunnel is on the medial side of the ankle, between the medial malleolus of the tibia and the calcaneus. It is not considered by most people to be an endangerment site. But, because the posterior tibial nerve can become entrapped here, in a condition called tarsal tunnel syndrome, it’s a good anatomical feature to keep in mind. The tibial artery and vein also run through the tarsal tunnel (Image 9).

Small Saphenous Vein

The small saphenous vein begins at the lateral ankle, and then wraps to the posterior side of the lower leg. It comes up between the heads of the gastrocnemius, and then dives into the popliteal fossa, where it joins the popliteal vein. The small saphenous vein is also prone to varicosities, and it’s something we need to keep in mind when working deeply in this area to access the soleus or deep foot flexors (Image 8).

Common Fibular Nerve

The common fibular nerve is vulnerable for a short distance just inferior to the head of the fibula. Specific pressure or friction on the fibularis longus can sometimes irritate this nerve, which will send shock-like electrical sensations down into the foot (Image 10).

In Conclusion

In conclusion, I want to reiterate two important points:

• Any place on the body can become an endangerment site if the massage therapist is uneducated, careless, or inattentive.

• An endangerment site is not a “no-go” area; it is an area where extra education and expertise are required to work safely if we’re doing anything more than gentle effleurage.

Remember, the target client for this discussion is someone who is fundamentally healthy and also not pregnant. Illness, recent surgery, injuries, and pregnancy obviously add to our list of cautions and concerns about potential endangerment sites. But, for most people, massage therapy is widely accepted as a remarkably safe intervention, especially compared to other ways people manage pain (e.g., with medications or surgery). We can each do our part to take the danger out of endangerment sites by knowing these areas well, getting advanced education to work here safely, and modifying our massage accordingly. If we do that, our insurance providers will thank us. And much more importantly, our clients will thank us.


Contributors and Reviewers

• Adrienne F. Asta, LMT

• Jill Kristin Berkana, LMT, BCTMB, Berkana Institute of Massage Therapy

• Kerry Jordan, LMT, Healwell

• Annie LaCroix, Columbia River Institute

• Whitney Lowe, Academy of Clinical Massage

• Til Luchau (with special thanks for providing the title), Advanced-Trainings

• Carole Osborne, BCMT, Body Therapy Education



Abilash, K., Mohd, Q., Ahmad, Z., & Towil, B. (2017). “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, 75–77. https://doi.org/10.5704/MOJ.1707.013

Aksoy, I. A., Schrader, S. L., Ali, M. S., Borovansky, J. A., & Ross, M. A. (2009). “Spinal Accessory Neuropathy Associated with Deep Tissue Massage: a Case Report.” Archives of Physical Medicine and Rehabilitation 90, no. 11, 1,969–72. doi:10.1016/j.apmr.2009.06.015

Behera, C., Devassy, S., Mridha, A. R., Chauhan, M., & Gupta, S. K. (2018). “Leg Massage by Mother Resulting in Fatal Pulmonary Thromboembolism.” The Medico-Legal Journal 86, no. 3, 146–150. https://doi.org/10.1177/0025817217706645

Chang, C.-Y., Wu, Y.-T., Chen, L.-C., Chan, R.-C., Chang, S.-T., & Chiang, S.-L. (2015). “Massage-Induced Brachial Plexus Injury.” Physical Therapy 95, no. 1, 109–116. https://doi.org/10.2522/ptj.20130487

Chen, H. L., Wu, C. C., & Lin, A. C. (2013). “Small Bowel Intramural Hematoma Secondary to Abdominal Massage.” The American Journal of Emergency Medicine 31, no. 4, 758.e3–758.e758004. doi:10.1016/j.ajem.2012.11.020

Cheong, H. S., Hong, B. Y., Ko, Y.-A., Lim, S. H., & Kim, J. S. (2012). “Spinal Cord Injury Incurred by Neck Massage.” Annals of Rehabilitation Medicine 36, no. 5, 708–12. https://doi.org/10.5535/arm.2012.36.5.708

Cho, J. Y., Moon, H., Park, S., Lee, B. J., & Park, D. (2019). “Isolated Injury to the Tibial Division of Sciatic Nerve After Self-Massage of the Gluteal Muscle with Massage Ball. Medicine 98, no. 19. https://doi.org/10.1097/MD.0000000000015488

Dutta, G., Jagetia, A., Srivastava, A. K., Singh, D., Singh, H., & Saran, R. K. (2018). “‘Crick’ in Neck Followed by Massage Led to Stroke: Uncommon Case of Vertebral Artery Dissection.” World Neurosurgery 115, 41–43. https://doi.org/10.1016/j.wneu.2018.04.008

Grant, A. C., & Wang, N. (2004). “Carotid Dissection Associated with a Handheld Electric Massager.” Southern Medical Journal 97, no. 12, 1,262–63. https://doi.org/10.1097/01.SMJ.0000145391.86504.CC

Grant, K. E. (2003). “Massage Safety: Injuries Reported in Medline Relating to the Practice of Therapeutic Massage—1965–2003.” Journal of Bodywork and Movement Therapies 7, no. 4, 207–12. https://doi.org/10.1016/S1360-8592(03)00043-3

Guo, Z., Chen, W., Su, Y., Yuan, J., & Zhang, Y. (2013). “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 & Traumatology: Orthopedie Traumatologie 23 Suppl 2, S149–153. https://doi.org/10.1007/s00590-012-1031-y

Hsu, P. C., Chiu, J. W., Chou, C. L., & Wang, J. C. (2017). “Acute Radial Neuropathy at the Spiral Groove Following Massage: A Case Presentation.” PM & R : The Journal of Injury, Function, and Rehabilitation, 9, no. 10, 1,042–46. doi:10.1016/j.pmrj.2017.03.010

Jabr F. I. (2007). “Massive Pulmonary Emboli After Legs Massage. American Journal of Physical Medicine & Rehabilitation 86, no. 8, 691. doi:10.1097/PHM.0b013e31811e2a7a

Jeon, C.-H., Chung, N.-S., Lee, H.-D., & Won, S.-H. (2019b). “Case Report: Electrical Automated Massage Chair Use Can Induce Osteoporotic Vertebral Compression Fracture.” Osteoporosis International: A Journal Established as Result of Cooperation Between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 30, no. 7, 1,533–36. https://doi.org/10.1007/s00198-019-04961-4

Kaur, J., Singla, M., Singh, G., & Singh, G. (2017). “Frequent Neck Massage Leading to Bilateral Anterior Cerebral Artery Infarction.” BMJ Case Reports 2017. https://doi.org/10.1136/bcr-2017-222169

Lee, T. H., Chiu, J. W., & Chan, R. C. (2011). “Cervical Cord Injury After Massage.” American Journal of Physical Medicine & Rehabilitation 90, no. 10, 856–59. doi:10.1097/PHM.0b013e318228c27c

Lim, D. C. G., Jayanthi, H. K., Money-Kyrle, A., & Ramrakha, P. (2009). “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., Tsai, T. C., & Chang, Y. Y. (1993). “Extracranial Internal Carotid Artery Dissection Secondary to Neck Massage: Visualization of Mural Hematoma by MRI.” Gaoxiong yi xue ke xue za zhi = The Kaohsiung Journal of medical sciences 9, no. 5, 322–27.

Mikhail, A., Reidy, J. F., Taylor, P., & Scoble, J. E. (1997). “Renal Artery Embolization After Back Massage in a Patient with Aortic Occlusion.” Nephrology, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant Association - European Renal Association 12, no. 4, 797–98. https://doi.org/10.1093/ndt/12.4.797

Mufarrij, A. J., & Hitti, E. (2011). “Acute Cystic Rupture and Hemorrhagic Shock After a Vigorous Massage Chair Session in a Patient with Polycystic

Kidney Disease.” The American Journal of the Medical Sciences 342, no. 1, 76–8. doi:10.1097/MAJ.0b013e31821a50c5

Posadzki, P., & Ernst, E. (2013). “The Safety of Massage Therapy: An Update of a Systematic Review.” Focus on Alternative and Complementary Therapies 18, no. 1, 27–32. https://doi.org/10.1111/fct.12007

Rahman, M. N., McAll, G., & Chai, K. G. (1987). “Massage-Related Perforation of the Sigmoid Colon in Kelantan.” The Medical Journal of Malaysia 42, no. 1, 56–7.

 Ryu, J. I., Han, M. H., Kim, J. M., Kim, C. H., & Cheong, J. H. (2018). “Cervical Epidural Hematoma That Induced Sudden Paraparesis After Cervical Spine Massage: Case Report and Literature Review.” World Neurosurgery 112, 217–20. doi:10.1016/j.wneu.2018.01.178

Tak, S., Tak, S., & Gupta, A. (2014). “Peripheral Embolisation After an Abdominal Massage.” BMJ Case Reports, 2014. https://doi.org/10.1136/bcr-2013-200827

Trotter, J. F. (1999). “Hepatic Hematoma after Deep Tissue Massage.” New England Journal of Medicine 341, no. 26, 2,019–20. https://doi.org/10.1056/NEJM199912233412616

Vanichkulbodee, A., Issaragrisil, S., & Inboriboon, P. C. (2019). “Massage-Induced Spinal Epidural Hematoma Presenting with Delayed Paraplegia.” The American Journal of Emergency Medicine 37, no. 4, 797.e1–797.e4. doi:10.1016/j.ajem.2019.01.017

 Wu, Y.-Y., Hsu, W.-C., & Wang, H.-C. (2010). “Posterior Interosseous Nerve Palsy as a Complication of Friction Massage in Tennis Elbow.” American Journal of Physical Medicine & Rehabilitation 89, no. 8, 668. https://doi.org/10.1097/PHM.0b013e3181c567af

Yang, S.-D., Chen, Q., & Ding, W.-Y. (2018). “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, e23–e26. https://doi.org/10.1097/PHM.0000000000000809

Yin, P., Gao, N., Wu, J., Litscher, G., & Xu, S. (2014). “Adverse Events of Massage Therapy in Pain-Related Conditions: a Systematic Review.” Evidence-Based Complementary and Alternative Medicine eCAM, 2014, 480956. doi:10.1155/2014/480956

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at BooksofDiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.