updated 8/02/08

Friction Massage Therapy for Tendonitis

A guide to a simple self-massage technique often helpful in resolving tendonitis

by Paul Ingraham, Vancouver, Canada (qualifications)

If you have tendonitis, or some conditions that are similar to tendonitis, you may be able to accelerate the healing process with a self-massage technique called “frictioning” or “friction massage.”1 The technique is particularly appropriate to use in cases of:

supraspinatus tendonitis, on the “tip” of the shoulder
tennis elbow or tendonitis of the common flexor or extensor tendons of the forearms, just below the elbow on the outside
achilles tendonitis, on the back of the heel and in the achilles tendon
DeQuervain’s tenovaginitis, along the thumb-side of the wrist

Friction massage basically “scrubs” the fibres of the tendon, aiding recovery. The mechanism is probably just stimulation.

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 extremely simple: just strum 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 across a guitar string.

Use gentle to moderate pressure with the pads of your fingers or a thumb.

Friction massage will cause discomfort — you are rubbing a tendonitis, after all! The pain “should” be clear and a bit burning or sharp — however, the intensity should be low. The discomfort should be vividly clear but nevertheless easily bearable.

If it is painless or the pain is dull, you are either 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 too severe to treat in this fashion.

The discomfort should subside significantly after one or two minutes. If it doesn’t, discontinue 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:

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

Finish by icing the massage site with raw ice for a maximum of two minutes, or until it is numb, whichever comes first. For more information about therapeutic icing and ice massage, see Icing for Injuries and Tendinitis.

The complete treatment should take about 3-6 minutes, and should be repeated 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.

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

How friction massage 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 irritated while healing, but nevertheless still needs some moderate stimulation in order to move tissue fluids and to induce connective tissue reorganization. This is the “use it or lose it” principle — biologically, it’s terribly important to avoid tissue stagnancy.

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

In the case of tendonitis, unfortunately, excessive “normal” usage of the tendon is precisely what caused the problem in the first place. If we “stimulate” the tendon with 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.

Is friction massage evidence-based?

Unfortunately, no — it’s only based on a good rationale. It simply “seems like a good idea” to some smart people. 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.’2

I have often seen good results from the application of friction massage in my own office.

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 that 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.

Some common conditions that often get mistaken for tendonitis

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 a irritation of a pad of fatty tissue underneath the tendon, not by the tendon itself. Friction massage is unlikely to provide the right kind of stimulation for this condition. For 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.

“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, it’s just as obviously not just a case of simple, classic inflammation. I don’t recommend friction massage for plantar fasciitis simply because there are several other excellent, cheap, easy and evidence-based treatment methods for it. However, feel free to try it! For more information about plantar fasciitis, see Save Yourself from Plantar Fasciitis!

A little more about muscle knots

Muscle knots (myofascial trigger points, or MTPs), are small, painful patches of dysfunctionally contracted muscle tissue. Generally speaking, MTPs routinely fool people into thinking that they have tendonitis.

Don’t be fooled!

Trigger points are way more common than tendonitis. 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.

Acute tendonitis has the sensitivity of an infected hang nail.

Muscle knots usually cause duller, more aching pain that rarely seems to be “in” a tendon.

Ironically, trigger points can often be treated easily by a wide variety of massage techniques. Thus, sometimes friction massage will seem to be successfully treating a tendonitis, when in fact it is successfully treating a muscle knot! However, usually friction massage is not the best way to tackle MTPs.

Nearly everyone has some problematic trigger points. That’s why SaveYourself.ca offers an extremely detailed trigger point tutorial:

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Notes

Hertling et al. Management of Common Musculoskeletal Disorders. An excellent technical overview of friction massage for professionals. Return to text.
Ibid., p137. Return to text.