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Can massage treat tendonitis?

Can massage treat tendonitis?

Deep Friction Massage Therapy for Tendonitis

A guide to a simple self-massage technique sometimes helpful in treating common tendonitis injuries like tennis elbow or Achilles tendonitis

2,400 words, updated 2012
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

If you have tendonitis, or a closely related problem, you may be able to accelerate healing with a self-massage technique called “frictioning” or “deep friction massage.”1 The technique may be appropriate to use in cases of:

Friction massage basically “scrubs” the fibres of the tendon, theoretically aiding recovery, and it doesn’t really have to be particularly “deep” (intense). If it works, the mechanism is probably just mild stimulation of natural tissue repair mechanisms. Friction massage is well worth trying, because it’s quite safe, basically free to experiment with, and makes a fair bit of sense even though it’s far from scientifically proven.2


After many months of persistent discomfort and limited range of movement, and after my third cortisone shot for thumb tendinitis and still no relief, I went searching and found your article about friction massage. I began the friction massage, and now, three days later, the discomfort is almost entirely gone! I'll continue with this for a while and see if I can eliminate it altogether. In the meantime, I shall once again pick up my violin, and play a tune of thanks for you!

Eloise Brandt, violinist

How to do friction massage

The action of friction massage is simple and well-suited to self-treatment, as long as you can reach the problem (and most tendonitis is reachable). Just rub gently back and forth over the inflamed tendon at the point of greatest tenderness. Your strokes should be perpendicular to the fibres of the tendon — like strumming a guitar string.

Use gentle to moderate pressure with the pads of your fingers or a thumb. Strong pressure is not required or wise, particularly for self-treatment. I’ll explain more about intensity as we go.

Even gentle friction massage will cause discomfort — you are rubbing an active case of tendonitis, after all! The pain should be clear and a bit burning or sharp — however, the discomfort should be easily bearable.

If the frictioning is painless, or the pain is dull, you are probably in the wrong place, or you don’t have tendonitis. If it is too painful, either you are pressing too hard, or the tendonitis is simply too serious to easily treat in this fashion.

The discomfort will subside significantly after one or two minutes. If it doesn’t, stop the treatment and try again later. If the tenderness does subside, increase the intensity until it returns. Wait for it to subside again. And increase it a third time, and wait a third time for the tenderness to ease. Like this:

  1. Friction for 1–2 minutes until sensitivity subsides.
  2. Increase intensity slightly. Friction for 1–2 minutes until sensitivity subsides.
  3. Increase intensity slightly. Friction for 1–2 minutes until sensitivity subsides.

Finish by icing the massage site, ideally with bare ice (for safety, ice only for a maximum of about two minutes, or until the spot is numb, whichever comes first). For more information about therapeutic icing and ice massage, see Icing for Injuries, Tendinitis, and Inflammation.

The complete treatment should take about 3-6 minutes, and should be done at least once per day, and a maximum of three times per day. If it’s going to work, you should feel immediate improvement in symptoms following each treatment. It may not work for you! This is no miracle cure. It is worth trying, but it fails in many cases for all kinds of reasons.

Friction massage treatments should be wrapped up by cooling the area down with an application of raw ice.

Friction massage treatments should be wrapped up by cooling the area down with an application of raw ice.


How friction massage works — if it works

Friction massage is basically a highly specific way to “use it or lose it.”

One of the basic principles of healing is that tissue must not be disturbed while healing, and this is particularly true of tendonitis, where stress has already exceeded the capacity of the body to adapt. And yet some stimulation is still a vital component of tissue health and healing, and it’s important to avoid tissue stagnancy. A sick tendon needs at least some moderate stimulation in order to move tissue fluids and to induce connective tissue repair.

In the case of tendonitis, excessive pulling on the tendon is precisely what caused the problem in the first place. If we “stimulate” the tendon with more pulling — more normal activity — this simply constitutes continued irritation to tissue that has already told us it “canna take it any more, cap’n!”

Thus, the friction massage technique provides a method of stimulating the tissue in a new and different way. In theory.

Provocative?

You could also describe frictioning as a form of provocation therapy, and certainly some professionals perform it that way.

There are two “laws” of tissue adaptation, one each for hard and soft tissue: Wolff’s law covers bone, but Davis’ law for soft tissue — muscles, tendons, and ligaments, fascia — is relatively obscure and imprecise. Many treatments are based on the idea of forcing adaptation or “toughening up” tissues. It has always been a reasonable idea, but what’s the “right” amount and kind of stress? Results vary widely. More provocative provocation therapies include the injecting of an actual irritant (prolotherapy), or scraping with edged massage tools (Graston Technique). See Tissue Provocation Therapies.

Friction massage can certainly be delivered with the more dramatic intent of affecting the structure of the tendon, regardless of how painful the treatment is. While it is possible that this could work, it’s obviously riskier, and I don’t recommend it — and the next section offers a particularly interesting reason.

Chronic tendonitis pain and neurology

The reductions in pain that occur at the time of applying the technique are easy enough to explain with “simple” neurology: almost anything that hurts will hurt less as you rub it and adapt to the stimulus. However, those pain-killing effects are also quite temporary. There is a way that neurology might actually account for a much more profound and lasting healing effect: by tinkering with sensitivity.

Chronic pain tends to be self-perpetuating. That is, pain can actually make you more sensitive to pain. In a lot of chronic pain cases, the problem is no longer in the tissue, but in nerves that have become oversensitive.45

Friction massage may interrupt this vicious cycle, by systematically “teaching” the nervous system to be less concerned about stimuli of the irritated tendon. Virtually any stimulation has the potential to do this, but the standard protocol for friction massage might just be particularly good: precisely manageable doses of sensation, repeated over and over again.

(And excessively painful doses of sensation might very well just make things worse! This is why I don’t recommend that “deep” friction massage should be particularly deep. Stick to the Goldilocks zone and you’ve got a chance of working on the problem in two different ways.)

It’s only another theory, but quite a nice one. If true, virtually any stimulation might do the trick — all that would matter is repeated doses of mild to moderate intensity.

Is friction massage based on evidence?

Unfortunately, no — there is almost no persuasive scientific research about friction massage, just a few slightly encouraging scraps.6 The absence of evidence is cause for concern — surely if the technique worked well it could have been proven by now? — but mostly it’s just a lack of research. The technique remains mostly based only on interesting and reasonable speculation about biology. It simply “seems like a good idea” to some smart people. Regarding the conventional rationale, Hertling and Kessler write:

Although highly conjectural, the effects of friction massage are based on sound physiologic and pathologic concepts …. Until there is more concrete evidence of the value of friction massage, its use must be justified on the [basis of clinical evidence] combined with ‘educated empiricism.’

And that remains the case today, despite the important “paradigm shift away from an active inflammatory model since the popularization of the deep friction massage technique by Cyriax” (Joseph et al).

The neurological perspective is my own take on it, which I’ve never seen anywhere else (but it is inspired by pioneers in pain research like Dr. Lorimer Moseley).

I often saw good results from the application of friction massage when I worked as a massage therapist, but that doesn’t really mean all that much. Many patients respond well to virtually any treatment — because virtually any kind of stimulation seems to have the potential to “reboot” a chronically painful situation in the body. In general, I prefer not to take credit for most of my “success stories.”

Are there any risks to friction massage?

Yes … but only if you are a bit reckless with it.

If you ignore excessive pain, you might accidentally attempt to friction massage something that isn’t tendonitis, and perhaps something that’s more vulnerable than tendonitis. For instance, if you try to friction massage a bursitis, you are probably going to really regret it for a few hours!

However, pain is an excellent guide. As long as you don’t persist when friction massage is too painful or showing no signs of working, you’re extremely unlikely to cause any harm.

If you ignore excessive pain, you might accidentally attempt to friction massage something that isn’t tendonitis

Otherwise, the worst case scenario is that you’ll waste a few minutes of your time. This is actually fairly likely. Although friction massage does seem to help many cases of tendonitis, unfortunately there are many conditions that get mistaken for tendonitis, and will therefore not be helped by friction massage.

Tendonitis-like conditions that may not respond as well to friction massage

Iliotibial band syndrome (ITBS), a.k.a. runner’s knee, is a common condition causing strong pain on the lateral surface of the knee. And it is almost certainly not a tendonitis, per se. Recent scientific evidence has clearly shown that ITBS is much more likely to be caused by irritation of tissue underneath the tendon, and not by the tendon itself. Friction massage is less likely to provide the right kind of stimulation for this condition, and that’s what evidence shows.7 For much more information about ITBS, see Save Yourself from IT Band Syndrome!

Iliotibial band syndrome is not a tendonitis, and probably cannot be helped by friction massage. In fact, ITBS is a greatly misunderstood condition in general. For more information, see SaveYourself.ca’s advanced tutorial about IT band syndrome.

Iliotibial band syndrome is not a tendonitis, and probably cannot be helped by friction massage. In fact, ITBS is a greatly misunderstood condition in general. For more information, see SaveYourself.ca’s advanced tutorial about IT band syndrome.

“Tennis elbow” may or may not be a “true” tendonitis, despite appearances. Myofascial pain syndrome (muscle knots) in the forearm is much more common than true tendonitis, and yet causes extremely similar symptoms. The main difference is a subtle difference in location and “hotness” and “sharpness” of the pain. Tendonitis will be a nastier, sharper, more burning pain with greater sensitivity to pressure—and felt primarily in the tendon. Myofascial pain syndrome will involve duller, more aching pain, with the greatest sensitivity just a little further “south” in the muscles. Since the two conditions routinely co-exist, aggravating each other, you’re unlikely to have a clear sense of the problem being one or the other. This also means that your milage with friction massage will vary — it may work well, or it may not work at all. For more information about tennis elbow, see Save Yourself from Tennis Elbow!

Plantar fasciitis, a common kind of pain in the arch of the foot, is another complex condition that is sort of like a tendonitis, but not really. Certainly it involves irritation of the connective tissue on the bottom of the foot, which is sort of like a tendon. However, plantar fasciitis is often more complex, and friction massage is more of a hail Mary treatment here — and meanwhile, there are some more evidence-based treatment methods for it. However, feel free to try a little friction massage! For (a lot) more information about plantar fasciitis, see Save Yourself from Plantar Fasciitis!

A little more about muscle knots

Muscle knots — myofascial “trigger points” — are a factor in most of the world’s aches and pains. Their biology is still mostly mysterious: conventional wisdom says they are tiny spasms, but they might also be a more pure neurological problem. Regardless, they can cause strong pain that often spreads in confusing patterns, and they grow like weeds around other painful problems and injuries, making them quite interesting and tricky. Although they are well known to many specialists and researchers, most doctors and therapists know little about them, so misdiagnosis is epidemic.

Triggers points fairly routinely fool people into thinking that they have tendonitis. Don’t be fooled! Surprisingly intense muscle pain is a much more common phenomenon than tendonitis (and tendonitis isn’t exactly rare). At their worst, muscle knots can be extremely painful and seem very, very much like a tendonitis. However, most muscle knots can’t hold a candle to the hot, burning intensity and extreme sensitivity of a tendonitis.

A true, acute tendonitis has the sensitivity of an infected hang nail — you can barely brush it or move the muscle without jumping in pain. Muscle knots usually involve duller, more aching pain that rarely seems to be “in” a tendon.

Trigger points can often be treated easily by a wide variety of massage techniques. Ironically, sometimes friction massage might seem to be successfully treating a tendonitis, when in fact it might be successfully treating a muscle knot.

Muscle pain is incredibly common. That’s why I offer a popular basic self-massage guide, as well as an extremely detailed trigger point e-book for people with tougher cases…

Save Yourself from Trigger Points & Myofascial Pain Syndrome

Myofascial trigger points — muscle knots — are increasingly recognized by all health professionals as the cause of most of the world’s aches and pains. This detailed tutorial focuses on advanced troubleshooting for patients who have failed to get relief from basic tactics, but it’s also ideal for starting beginners on the right foot, and for pros who need to stay current. 193 sections grounded in the famous texts of Drs. Travell & Simons, as well as more recent science, this constantly updated tutorial is also offered as a free bonus (2-for-1) with the low back, neck, muscle strain, or iliotibial pain tutorials. Add it to your shopping cart now ($19.95) or read the first few sections for free!

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Further Reading

Notes

  1. Hertling et al. Management of Common Musculoskeletal Disorders.

    An excellent technical overview of friction massage for professionals.

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  2. When choosing treatments, please be wary of The Three D’s of Quackery: treatments that may be dangerous, dubious, and distracting (costly or time-consuming). No pain treatment is perfect, but does it at least make sense? Is it safe? Cheap? Reasonably convenient? Friction massage does quite well when considered in this way. BACK TO TEXT
  3. Khan et al. Overuse tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed. 2000. PubMed #20086639. “Numerous investigators worldwide have shown that the pathology underlying these conditions is tendinosis or collagen degeneration.” For much more about this, see my Repetitive Strain Injuries Tutorial. BACK TO TEXT
  4. Woolf. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010. PubMed #20961685.

    Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people

    For a more information about this paper, see Pain Changes How Pain Works.

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  5. SY Ingraham. Pain is Weird: Pain science reveals that pain is a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it. SaveYourself.ca. 7616 words. BACK TO TEXT
  6. Joseph et al. Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sport Rehabilitation. 2012. PubMed #23118075. Comments: This review of the “efficacy of deep friction massage (DFM) in the treatment of tendinopathy” concludes that there’s basically still no hard data, and “its isolated efficacy has not been established.” BACK TO TEXT
  7. Brosseau et al. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews. 2002.

    This is a systematic review of two randomised clinical trials (RCTs) on the efficacy of deep transverse friction massage in the treatment of tendinitis. Although these trials showed “no benefit of deep transverse friction massage,” they were also much too flawed. The review authors mainly showed that “no conclusions can be drawn,” and that “future trials, utilizing specific ITBFS methods and adequate sample sizes are needed.”

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