For many massage therapists, extremely demanding exercise programs are a boon to business. With a mildly torn hamstring or twisted knee, many people are more likely to simply wait for the pain to subside than to visit the doctor. Some of those injured people, however, may take the additional enlightened step of visiting their massage therapist.
In this situation, massage therapists can become an important part of clients’ fitness strategies. Our ability to help people understand and appreciate their bodies, along with the work massage can do to aid in recovery, can be big factors in staying injury-free.

Exercise: All or Nothing
Americans tend to pitch full speed into any given commitment. If we’re going to get fit, by golly, we’re going to do it now, regardless of how long it took us to get into our current state. Moderation is not in our nature. This is reflected in the catchphrases often seen on T-shirts, bumper stickers, and social media that promote the “all or nothing” spirit:
• “When I exercise I wear all black—it’s like a funeral for my fat.”
• “Victory comes at a price. What are you willing
to pay?”
• “Their workout is our warm-up.”
Of course, starting a fitness program doesn’t mean we’ll actually finish it. This is often because when a person throws herself into an overambitious new routine, the chances of her incurring an injury are high. Then she has to stop; she gets discouraged, and may give up entirely, only to start the cycle over in another year or so.
Exercise is only effective if it occurs without injury. Even a comparatively easygoing program requires some thoughtfulness, and any type of exercise is safer and more successful when new participants build up their activity levels carefully, listen to their bodies to know when enough is enough, and receive excellent guidance about form.
Sadly, exercising restraint when we work out is difficult. Combine our competitive drive with poorly trained coaches who give bad advice about form, pacing, and effort, and we have a recipe for problems that range from ruptured tendons to herniated disks. One massage therapist I spoke to told me this story:
“A client came in with back pain after a workout. She hadn’t done any exercise for over a year. On the first day, they pushed her to lift heavy weights, and she just wanted to use the bar without weights. The trainer didn’t let up on pressuring her to do more, and she gave in. There seems to be an attitude to push yourself too hard, ignoring medical issues or fitness levels.”
The problem is made worse by the dangerous trend of regarding pain and injury as a sign that you’re doing it right, as shown in some more common “inspirational” slogans:
• “Willpower knows no obstacles.”
• “No limits, no rules, no fear.”
• “You can cry, just don’t be a baby.”
• “Pain is nothing compared to what it feels like to quit.”
Some massage therapists welcome this trend as a source of new clients and job security, but for our clients’ best interests, we also need to use our skills to help them avoid the worst of what rigorous exercise can do.
Any exercise program can be taken too far and lead to injuries. CrossFit is one program with a reputation for being especially demanding; its risks depend greatly on the expertise of the trainer and the participant’s ability to judge his or her own limits. “I had a CrossFit client who had done repeated squats until his quads were so sore he cried out in pain from my light touch,” a therapist told me. “I literally could not even touch him.”
Zumba, Jazzercise, and similar dance-based programs also carry a high potential for injury: the risk of twisting at the knee is high, and foot problems, including sprained ankles, plantar fasciitis, and stress fractures, appear to be common.
Even yoga can be a source of soft-tissue injury. Overstretching can lead to muscle tears and delayed soreness, and repeated injuries can lead to chronic problems at the neck and sacroiliac joints. One therapist reported seeing several injuries related to a prolonged yoga headstand, probably in a student who was not ready for this challenge.
These reports are purely anecdotal and not recorded in any official literature, but they reflect the experience of many massage therapists who generously shared their experiences.
One common theme in most of these anecdotes is that people get injured when they do more than is good for them. Their self-awareness is an undeveloped sense, so they don’t know how to pay attention to the signals of impending injury.

Why It Goes Wrong
Human bodies are designed to efficiently manage soft-tissue injuries. In the best circumstances, we heal quickly and completely, with a minimal amount of high-functioning internal scar tissue, and function returns to normal or near-normal levels. When things are ideal, that sprained ankle you got playing soccer at age 12 doesn’t interfere with your ability to walk in your 30s. The lumbar strain from picking up that heavy laundry basket 15 years ago doesn’t get in the way of your golf game today.
But when we introduce a new exercise program, especially one that is different or more demanding than we have experienced before, we risk flare-ups of old lesions where scar tissue does not have the weight-bearing capacity of healthy muscle or connective tissue. This is when that long-ago sprained ankle may make itself known, and that old weakness in your back will definitely have opinions about your ambitious new routine. Add to this any number of fresh injuries that can arise from the new program, and it can feel like your new commitment to fitness was maybe not the best idea.

What Does the Research Say?
A quick scan of the published research about exercise-induced injuries reveals some interesting findings.
Not surprisingly, evidence suggests that aging is associated with longer healing times for basic muscle injuries. But it was also found that among ultra-distance runners, younger, less-experienced athletes sustain more injuries than their older cohorts. This illustrates the importance of careful training and appropriate building up to any demanding physical activity.
Most of the injuries that were studied in runners were fairly minor and mostly related to knee problems or stress fractures in the feet. They led to a decrease in training days, but not in significant lost work time or hospital stays; they were not typically reported to primary care providers. This is appropriate, since most doctors can do little for minor musculoskeletal injuries beyond suggesting anti-inflammatories and temporary rest: a strategy we can do for ourselves.
One exception to this rule occurs when muscle injury coincides with kidney damage. This can happen in a few different ways, but the basic sequence is when muscle damage (from any cause, including overaggressive exercise) leads to the release of inflammatory chemicals and—in extreme cases—the by-products of dying muscle cells. The body’s effort to remove these substances can overload the kidneys, irritating them or even damaging them to the point of failure. Research suggests that this is a higher risk factor in hot conditions, like a summertime marathon or a dehydrated person exercising in an overheated gym.
The most extreme example of muscle injury-related kidney damage is called rhabdomyolysis, which can be life-threatening. It isn’t common, but it needs to be on the radar of extreme exercise enthusiasts and anyone who treats them. Signs and symptoms of this medical emergency include a tender, weak affected muscle, along with dark red or brown urine. Rhabdomyolysis patients need medical treatment immediately, and it may be a prolonged period before they can resume physical activity.

Implications for Massage Therapy
Massage therapists are health-care advocates, and it is reasonable for our clients to turn to us for good advice. This puts us in a tight spot when our client—who we know has real problems with low-back stability, or knee pain, or high blood pressure—tells us how excited he is to be starting a demanding exercise program. While our unspoken thought might be, “Are you nuts?” our more measured reply needs to acknowledge the client’s desire to work for good health, and offer our strictly within-scope advice for how he might safely achieve his goals.
One of the most important pieces of advice we can offer is for clients to fully evaluate the trainers or leaders of the exercise program they want to start. Poorly educated leaders appear to be a major factor in injury risk: they can miss signs of poor form and posture, or they can specifically coach a person to go too far, in the belief that they are being appropriately challenging. It is also critical that the client report any known medical conditions (an old herniated disc, a history of knee surgery, etc.) to the class instructors, in case they need to make special accommodations.
We can also make suggestions about good form, and exercise duration and frequency. We might have ideas about warm-ups, cool-downs, and postexercise stretching. We can point the client to his or her exercise program director for specific supervision to help prevent future injury. And if that person appears to be giving bad advice (“suck it up”—a real response from one trainer—is not an appropriate way to manage knee pain, for instance), then we can suggest that our client might want to look for some other options.
Perhaps the single most valuable thing massage therapy offers for clients who want to challenge themselves and become more fit and healthy is the chance to become more aware of their own bodies, in a powerfully positive way. In this way, they can move with intention and consciousness. Increased body awareness and self-appreciation may be the best tools for helping our clients increase activity levels without hurting themselves. This is how we can help clients achieve their goals: not with pain and injury, but with power and joy.

Ruth Werner is a former massage therapist, a writer, and an NCTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

To read this article in our digital issue, click here.