Common Pathologies & Referral Guidelines

Massage therapists work with clients who have a wide range of health conditions. Understanding common pathologies, their signs and symptoms, and when to refer to a physician is essential for safe, effective practice.

---

The Inflammatory Process

Inflammation is the body's natural response to tissue injury, infection, or irritation. The five cardinal signs of inflammation are:

Acute vs. Chronic Inflammation

---

Common Musculoskeletal Conditions

Fibromyalgia

• Definition: Chronic condition characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties ("fibro fog")
• Key features: Pain in multiple body regions for 3+ months; tender points; associated with depression and anxiety
• Massage considerations: Use gentle, moderate-pressure techniques within client tolerance. Avoid deep tissue work on flare-up days. Massage can help reduce pain and improve sleep quality.

Osteoarthritis (OA)

• Definition: Degenerative joint disease — articular cartilage wears down over time
• Key features: Joint pain and stiffness (worse with activity, better with rest), crepitus, reduced ROM, Heberden's nodes (DIP joints) and Bouchard's nodes (PIP joints)
• Massage considerations: Avoid direct pressure on acutely inflamed joints. Gentle ROM exercises and massage around the joint can improve circulation and reduce stiffness.

Rheumatoid Arthritis (RA)

• Definition: Autoimmune disease that attacks the synovial membranes of joints
• Key features: Bilateral/symmetrical joint involvement, morning stiffness lasting >30 minutes, joint deformity over time, systemic symptoms (fatigue, fever)
• Massage considerations: Avoid massage during acute flare-ups. During remission, gentle massage may help. Always obtain physician clearance.

Tendinitis vs. Tendinosis

Trigger Points

• Definition: Hyperirritable spots within taut bands of skeletal muscle that produce local and referred pain
• Types: Active (cause spontaneous pain and referral patterns) and latent (only painful when pressed)
• Treatment: Ischemic compression, trigger point release, positional release, stretching
• Key referral patterns:
  • Upper trapezius → temporal headache (side of head)
  • SCM (sternocleidomastoid) → frontal headache, dizziness, visual disturbances
  • Infraspinatus → anterior shoulder and arm pain
  • Piriformis → buttock and posterior thigh pain (mimics sciatica)
  • Levator scapulae → angle of the neck, medial scapular border
  • Gluteus minimus → lateral thigh and leg pain (mimics sciatica)
  • Subscapularis → posterior shoulder and wrist pain
  • Soleus → heel and plantar foot pain

Healing Process Phases

Understanding the stages of tissue healing guides massage treatment decisions:

Common Skin Conditions

---

When to Refer to a Physician

Red Flags Requiring Immediate Referral

Massage therapists must refer clients to a physician when they identify:

• Unexplained weight loss (>10% body weight without trying)
• Constant pain at night that is not relieved by position changes
• Bowel or bladder dysfunction (possible cauda equina syndrome)
• Signs of stroke (FAST): Face drooping, Arm weakness, Speech difficulty, Time to call 911
• Signs of DVT (deep vein thrombosis): Unilateral leg swelling, redness, warmth, and calf pain
• Unexplained lumps or masses
• Signs of infection: Fever, red streaks, pus, rapidly spreading redness
• Severe headache described as "the worst headache of my life"
• Numbness or tingling that is progressive or accompanied by weakness
• Recent unexplained bruising or bleeding abnormalities

---

Additional Common Conditions

Carpal Tunnel Syndrome

• Definition: Compression of the median nerve as it passes through the carpal tunnel at the wrist
• Symptoms: Numbness, tingling, and pain in the thumb, index, middle, and half of the ring finger; weakness in grip
• Massage considerations: Massage of the forearm flexors and gentle wrist mobilization may help; avoid direct deep pressure over the carpal tunnel; refer for medical evaluation
• Common in: Office workers, massage therapists, anyone with repetitive wrist motions

Thoracic Outlet Syndrome (TOS)

• Definition: Compression of nerves and/or blood vessels between the clavicle and first rib
• Symptoms: Pain, numbness, and tingling in the arm and hand; may be vascular (swelling, discoloration) or neurogenic (more common)
• Massage considerations: Release tight scalenes, pectoralis minor, and SCM; improve posture; avoid positions that reproduce symptoms

Sciatica

• Definition: Pain radiating along the sciatic nerve (lower back through the buttock and down the leg)
• Causes: Herniated disc, piriformis syndrome, spinal stenosis, degenerative disc disease
• Massage considerations: Address piriformis and gluteal muscles; avoid deep pressure on the lumbar spine if disc involvement is suspected; refer for medical evaluation if symptoms are severe or progressive

Plantar Fasciitis

• Definition: Inflammation and degeneration of the plantar fascia on the bottom of the foot
• Symptoms: Sharp heel pain, especially with first steps in the morning
• Massage considerations: Deep friction massage of the plantar fascia, stretching of the gastrocnemius and soleus, cross-fiber friction at the calcaneal attachment

Temporomandibular Joint Dysfunction (TMJ/TMD)

• Definition: Pain and dysfunction of the temporomandibular joint and associated muscles
• Symptoms: Jaw pain, clicking/popping, difficulty opening the mouth, headaches, ear pain
• Massage considerations: Gentle massage of the masseter, temporalis, medial and lateral pterygoids (intraoral work requires special training and consent); address SCM and suboccipital muscles