3.2 Contraindications & Medications
Key Takeaways
Absolute (general) contraindications mean massage should NOT be performed at all: fever, acute systemic infection, DVT/PE, severe uncontrolled hypertension
Local contraindications mean massage should be avoided in a specific area but can continue elsewhere: varicose veins, skin infections, open wounds, recent surgery site
Endangerment sites are areas where nerves, blood vessels, or organs are superficial and vulnerable to damage from pressure
Key endangerment sites include the anterior triangle of the neck, axilla, cubital fossa, femoral triangle, popliteal fossa, and kidney area
Blood thinners (anticoagulants like warfarin, heparin) increase bruising risk — reduce pressure and avoid deep tissue work
Muscle relaxants and pain medications may mask pain feedback — use lighter pressure and communicate frequently
NSAIDs (ibuprofen, naproxen) reduce inflammation and pain perception — client may not feel discomfort during deep work
Corticosteroids (prednisone) can weaken connective tissue with long-term use — use reduced pressure
Understanding contraindications and medication effects is critical for client safety. A contraindication is any condition that makes a particular treatment inadvisable or potentially harmful.
Types of Contraindications
Absolute (General) Contraindications — Do NOT Massage
These conditions mean massage should not be performed at all until the condition resolves or a physician provides clearance:
| Condition | Reason |
|---|---|
| Fever (above 100.4F / 38C) | Indicates systemic infection; massage can spread infection and worsen symptoms |
| Acute systemic infection | Risk of spreading infection; immune system is compromised |
| Deep vein thrombosis (DVT) | Risk of dislodging the clot, causing pulmonary embolism (life-threatening) |
| Pulmonary embolism | Medical emergency — immediate medical care needed |
| Severe uncontrolled hypertension | Risk of stroke or cardiovascular event |
| Acute cardiac conditions | Unstable angina, recent heart attack, uncontrolled arrhythmias |
| Severe bleeding disorders | Risk of hemorrhage |
| Eclampsia / severe preeclampsia | Medical emergency requiring immediate treatment |
| Anaphylaxis | Medical emergency |
| Intoxication (alcohol/drugs) | Impaired consent, altered pain perception, vasodilation |
Local Contraindications — Avoid the Specific Area
These conditions mean massage should be avoided in the affected area but can continue on other parts of the body:
| Condition | Area to Avoid |
|---|---|
| Open wounds, burns, skin lesions | The wound and surrounding area |
| Skin infections (fungal, bacterial, viral) | Infected area — contagious via contact |
| Varicose veins | Directly over the veins |
| Recent surgery site | Surgical area until cleared by physician |
| Acute inflammation (acute tendinitis, bursitis) | The inflamed area |
| Undiagnosed lumps or masses | The area until evaluated by physician |
| Bruising or hematoma | The bruised area |
| Sunburn | Affected skin |
| Hernia | The hernia site |
| Skin cancer or melanoma | The lesion and surrounding area |
Endangerment Sites
Endangerment sites are areas where nerves, blood vessels, or organs are close to the surface and vulnerable to injury from massage pressure. Extra caution is required in these areas.
| Endangerment Site | Location | Vulnerable Structures |
|---|---|---|
| Anterior triangle of the neck | Between SCM, mandible, and trachea | Carotid artery, jugular vein, vagus nerve, thyroid gland |
| Posterior triangle of the neck | Between SCM, trapezius, and clavicle | Brachial plexus, subclavian artery, external jugular vein |
| Axilla (armpit) | Under the arm | Axillary artery/vein, brachial plexus, lymph nodes |
| Cubital fossa (antecubital) | Anterior elbow crease | Brachial artery, median nerve, ulnar nerve |
| Femoral triangle | Anterior upper thigh (medial) | Femoral artery/vein, femoral nerve |
| Popliteal fossa | Posterior knee | Popliteal artery/vein, tibial nerve, common peroneal nerve |
| Kidney area | Posterior lower ribs (T12-L3) | Kidneys (no bony protection below ribs) |
| Sternal notch | Superior border of sternum | Trachea, brachiocephalic vein |
| Ulnar notch (funny bone) | Medial elbow | Ulnar nerve |
| Abdomen | Below ribs, above pelvis | Abdominal aorta, inferior vena cava, intestines, liver |
Common Medications & Massage Implications
Medications That Affect Massage Therapy
| Medication Class | Examples | Massage Implications |
|---|---|---|
| Anticoagulants / Blood thinners | Warfarin (Coumadin), heparin, rivaroxaban | Increased bruising risk; reduce pressure; avoid deep tissue |
| NSAIDs (Anti-inflammatories) | Ibuprofen, naproxen, aspirin | Reduced pain perception; client may not feel discomfort — use caution with pressure |
| Muscle relaxants | Cyclobenzaprine (Flexeril), methocarbamol | Altered pain/tension feedback; use lighter pressure |
| Opioid pain medications | Oxycodone, hydrocodone, morphine | Severely impaired pain feedback; reduced pressure essential |
| Corticosteroids | Prednisone, dexamethasone | Long-term use weakens connective tissue; reduce pressure |
| Antihypertensives | Lisinopril, metoprolol, amlodipine | May cause orthostatic hypotension; assist client rising slowly |
| Antidepressants | Sertraline (Zoloft), fluoxetine (Prozac) | May alter pain perception; communicate about pressure |
| Insulin / Diabetes medications | Insulin, metformin | Risk of hypoglycemia; ensure client has eaten; watch for dizziness/confusion |
| Chemotherapy drugs | Various | Immune suppression; avoid deep work; follow oncology massage protocols |
Key Rules for Medications and Massage
- Always ask about medications during the health intake process
- Never advise a client to change, stop, or adjust their medication
- When in doubt, get physician clearance before providing massage
- Adjust pressure based on the medication's effects on pain perception and tissue integrity
- Document all reported medications on the client intake form
A client with a suspected deep vein thrombosis (DVT) in their left calf requests a leg massage. The massage therapist should:
Massage the right leg only and avoid the left
Perform very light massage on the affected calf
Refuse to perform any massage and refer to a physician immediately
Use ice on the area first, then massage
Which of the following is a LOCAL contraindication to massage?
Fever of 101F
Deep vein thrombosis
An open wound on the forearm
Severe uncontrolled hypertension
The anterior triangle of the neck is an endangerment site because it contains:
The brachial plexus and subclavian artery
The carotid artery, jugular vein, and vagus nerve
The femoral artery and nerve
The ulnar nerve
A client takes warfarin (Coumadin), a blood thinner. The massage therapist should:
Refuse to massage the client
Perform deep tissue massage as normal
Reduce pressure and avoid deep tissue techniques
Advise the client to stop the medication before the session
Match each endangerment site to its location on the body.
Match each item on the left with the correct item on the right
Femoral triangle
Popliteal fossa
Cubital fossa
Axilla
A client is taking opioid pain medication. Why is this important for the massage therapist to know?
Opioids make muscles more resistant to massage
Opioids severely impair pain feedback, so the client may not feel excessive pressure
Opioids strengthen connective tissue
Opioids have no effect on massage therapy
Which of the following are absolute (general) contraindications to massage? (Select all that apply)
Select all that apply
Fever above 100.4F
Varicose veins on the lower leg
Pulmonary embolism
Sunburn on the shoulders
Deep vein thrombosis (DVT)
Intoxication
The popliteal fossa is an endangerment site located:
In the anterior elbow crease
Behind the knee
In the groin area
Under the armpit
A client with high blood pressure takes antihypertensive medication. What should the massage therapist be most aware of?
The client may have an allergic reaction to massage oil
The client may experience orthostatic hypotension (dizziness when standing up)
Deep tissue work is contraindicated in all hypertensive clients
The client should not receive any massage until blood pressure is normal
Arrange the following skin conditions from MOST to LEAST contagious concern for a massage therapist.
Arrange the items in the correct order
Ringworm (fungal infection — highly contagious by direct contact)
Psoriasis (non-contagious autoimmune condition)
Eczema (non-contagious inflammatory condition)
Impetigo (bacterial infection — contagious)
Sections you finish are checked off in the contents.