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As Mark Twain famously observed, “To aman with a hammer, everything lookslike a nail.” In the context of health con-

cerns, this means that the tools most easilyavailable to us—including our theories, assump-tions, testing procedures, and technical skills—have a tremendous impact on the type of carewe provide. Thus, health professionals in differ-ent fields may offer dramatically differentassessments and treatments for the samecondition. For instance, in cases of painand injury, we would expect chiropractorsto address spinal misalignments, acupunc-turists to emphasize the flow of energy(Qi), and surgeons to consider more surgi-cal options. Within the field of massagetherapy (and related forms of bodywork),the focus has typically been on musclesand more recently on fascia.

Over the past few decades, many healthprofessionals have begun seeking therapeu-tic alternatives outside their traditionalmodes of practice. Physicians are workingin collaboration with chiropractors andreferring more and more patients to mas-sage therapists. Chiropractors are broaden-ing their areas of expertise, learning how towork with a wide variety of soft tissueinjuries. Massage therapists, too, have beenintegrating new knowledge and skills into theirwork. Some of these changes—including anincreasing reliance on the principles of orthope-dic massage—have allowed practitioners to dra-matically increase their effectiveness.

When I use the term orthopedic massage, I amreferring to precise techniques for assessing,understanding, and treating musculoskeletalpain and injury. These techniques are based onthe principles of orthopedic medicine developedby Dr. James Cyriax. He was one of the firstphysicians to take a scientific approach to mus-culoskeletal pain that did not require surgery.Working in England in the 1940s, Cyriax foundthat most of the ideas about assessing and treat-ing pain that were current at that time wereincorrect. He developed his own approach—out-lining systematic assessment procedures that

enable a practitioner to clearly identify whatstructure or structures have been injured, aswell as guidelines for determining whatmethod(s) of treatment will be most effectivefor each individual.

Orthopedic medicine is “color blind” as towhich approach is best for treating a given indi-vidual or condition. This means one would recommend and apply the therapy that is best

suited to a given person’s problem rather thanthe therapy he or she knows best. In addition to hands-on therapy, a skilled practitioner oforthopedic massage might recommend specificexercises, manipulation performed by a chiro-practor or osteopath, or sessions with a teacherof the Feldenkrais Method or AlexanderTechnique. The practitioner may also consultwith a physician to explore whether injectiontherapy might be effective when other interven-tions have failed.

Studying with Cyriax more than twenty-fiveyears ago transformed my practice and my teach-ing, leading to much greater success in treatment.In this article, I’ll use the principles of orthopedicmedicine as applied to massage therapy to offerinsight into what I see as five misconceptionsthat are prevalent in our profession.

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Misconception Number OneMuscles are a major source

of pain and injury. Massagetherapists spend a large portion oftheir training learning about mus-cles; therefore, when somethinggoes wrong in the body, musclesare naturally the first place theylook. When a client is in chronicpain, the practitioner might attrib-ute that discomfort either to amuscle spasm or to injured mus-cle tissues. However, as we’ll see,this is often not the case.

First let’s look at musclespasms, which are frequentlyidentified as a source of pain. In my experience, most cases of muscle spasms are actually the result of an injury to someother tissue. They function as aprotective mechanism to helpavoid further injury. For example,if a ligament or a nerve root inyour low back is injured, yourbody will work to prevent youfrom causing further damage: Asyou start to move in a way thatexacerbates the injury, your low-back muscles will contract orspasm involuntarily.

Even when a muscle is directlyinjured, this is unlikely to causeserious pain problems for verylong. Although muscle strainsand micro-tears occur very fre-quently, muscles are highly vascu-larized and therefore heal veryquickly.1 A pain that developsafter performing some activityand then disappears after anight’s sleep or a few days of restis often the result of a muscleinjury. In contrast, tendons andligaments have a very limitedblood supply, so without propertreatment they heal quite slowly (if at all). These tis-sues are frequently injured, and are a major cause ofchronic musculoskeletal pain. Joints are another com-mon source of pain, with joint damage occurring morefrequently as we age. Finally, injuries to fascia maycause chronic pain in many parts of the body as well.Knowledge about each of these structures is essentialfor us to be able to effectively assess and treat ourclients’ pain problems. Certainly, a thorough under-standing of muscle anatomy and function is also nec-essary, but it is not sufficient.

Misconception Number TwoIncreasing circulation is the major task in heal-

ing an injured tissue. Healing of musculoskeletalinjuries is affected by a wide variety of factors, fromnutrition and emotional stress to body alignment andexercise habits. Circulation is one key factor, andincreased blood flow to injured tissues is often high-lighted as a major benefit of massage. However, manypractitioners are unaware of a more important contri-bution they can make toward the healing of injuries—helping to eliminate adhesive scar tissue.2

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Many therapists do not fully understand the processby which soft-tissue injuries lead to chronic pain con-ditions. Often, chronic pain results when an injuryheals improperly, with poorly formed adhesive scar tis-sue. In a healthy healing process, scar tissue serves asthe biological glue that holds torn fibers together inproper alignment. However, in many cases, the processgoes awry. Scar tissue builds up in a jumbled mass ofadhesions, forming a weakened structure that is vul-nerable to re-injury. A vicious cycle begins—the tissuetears again and again, each time causing more painand the creation of more adhesive scar tissue.3

Breaking this cycle isthe key to effectivetreatment. Existingadhesive scar tissuecan be broken upthrough the use ofcross-fiber (transverse)friction and, in moreserious cases, manipu-lation or injection ther-apy. Then, to preventadhesions from contin-ually forming, the bodypart must be regularlymoved through its fullrange of movement during the healing process. Forinstance, while sprained ankle ligaments are healing,the ankle must be moved in all directions, not keptstill. With a better understanding of how to eliminateadhesive scar tissue and prevent its re-formation, mas-sage therapists can help their clients heal much morequickly and stay well for the long term.

Misconception Number ThreeThe injury is located where the pain is felt. The

location of a client’s pain is often misleading. In manycases, pain is “referred” from the source of injury toanother part of the body. For example, pain felt only inthe upper arm is often caused by an injured shouldertendon,4 and pain felt around the scapula is oftencaused by a sprained neck ligament.5 Only certainareas of the body are significant sources of referredpain; these include the shoulders, neck, thorax, lowback, sacrum, buttocks, and hip joints. The distaljoints of the knee, foot, ankle, elbow, wrist, and handdo not refer pain any appreciable distance.

An in-depth understanding of referred pain is criti-cal for pinpointing the exact location of an injury.Keep in mind these four principles:

• Pain refers distally. Referred pain from soft tis-sue injuries is usually felt distally (i.e., out towardthe periphery of the body).6 For example, pain maybe referred from the neck or shoulder down to thewrist, but not from the elbow or wrist up to theneck.

• Referred pain does not cross the midline. Painnever refers from the left side of the body to theright, or from the right side to the left.7 If a clientexperiences pain in the right shoulder that seemsto travel to the left shoulder, that person actuallyhas two injuries—one on each side.

• Distance indicates severity. The distance a painrefers is directly proportional to the severity of theinjury.8 A mild shoulder injury may refer pain tothe bottom of the deltoid muscle, while a severeone can refer all the way down to the wrist.

• Referred pain follows the dermatomes. Aninjured structure willrefer pain only toother areas within thesame dermatome—i.e.,tissues that arose fromthe same segment inembryological develop-ment.9 Various struc-tures within the samedermatome can causesimilar referred painpatterns. For example,pain referred to thearm from the shoulderis usually in a C5 der-

matome distribution (see illustration) and may becaused by damage to a rotator cuff tendon, shoul-der joint, or bursa in the shoulder. The parts of theshoulder that are located within other dermatomeswill cause different patterns of referred pain.

Misconception Number FourPain caused by active movements gives a good

indication of what structure is injured.Orthopedic medicine differentiates between threemain types of movement: resisted, passive, and active.For determining the location of an injury, tests ofactive movement provide the least reliable and leastimportant information.

Resisted tests—isometric contractions against resist-ance—test for injury to structures that initiate movement(muscles and tendons). They also test for weakness,which may be caused by disc pressure on a nerve. Passivetests—in which the client behaves like a rag doll while

Over the past few decades,many health professionals

have begun seeking therapeuticalternatives outside their

traditional modes of practice.

A U G U S T / S E P T E M B E R 2 0 0 6 • M A S S A G E & B O DY WO R K 123

C5 dermatome distribution.

being moved by the therapist—test for injury to struc-tures that do not initiate movement (ligaments, joints,and bursas). In active tests, the person moves her bodythrough space by herself. This simultaneously tests boththe structures that initiate movement and those that donot, making it difficult to tease out what is causing thepain.10

Misconception Number FiveThe theory of trigger points can effectively

explain the underlying causes of musculoskeletalpain. This final misconception is the most controver-sial one. The theory of trigger points, as articulated byTravell and Simons, is very cogent and influential, andyet it runs in direct contrast to Cyriax’s principles oforthopedic medicine.

According to Travell and Simon’s theory, a myofascialtrigger point is a hyperirritable point on a muscle associ-ated with a sensitive nodule in a band of myofascial tis-sue. Palpation of this spot produces pain, tenderness,motor dysfunction, and other symptoms within a targetzone, which is usually (though not always) removedfrom the location of the trigger point. Referred pain andtenderness appear in particular classic patterns andsometimes cross the midline. The pain does not followthe dermatomes, and it can mimic the referred pain pat-terns of nerve root compression, zygapophyseal joints,and viscera.11, 12, 13, 14 (Note the contrast to the orthopedicprinciples of referred pain in orthopedic medicine, asoutlined in Misconception Number Three.)

Adherents of this theory work to identify specificpoints on the body that produce pain when com-pressed, needled, etc. Signs used to confirm the pres-ence of a trigger point include: a local twitch response;altered sensation in the target zone; painful limit to afull range of motion; EMG evidence of spontaneouselectrical activity; pain when the muscle is contracted;weakness on muscle testing; damp skin in that area;rough skin in that area; and a “jump” sign on palpa-tion. When a trigger point is located, recommendedtreatments may include trigger point pressure release,muscle energy techniques, positional release, spray andstretch techniques, wet or dry needling, injection, or anumber of other options.15, 16

Orthopedic medicine specialists take a very differentperspective on the issue of trigger points and believethem to be secondary phenomena, subsidiary to theprimary cause of pain. My own experience and my discussions with physicians who practice orthopedicmedicine strongly support this view.

Consider the following example. If a person has signifi-cant referred pain down the leg as a result of sacroiliacligament sprain (the primary injury), the leg will beexperienced as very painful, even though there is nopathology in the leg. As a result of the referred pain inthe leg, the person’s leg muscles will react by contractingand constricting its fibers over time. This forms chronic,

In orthopedic assessment, passive and resistedtests provide more useful information thanactive tests. Below are photos of a singlemovement—side-flexion of the neck— performed in each of those three ways.

Three Varieties of Orthopedic Testing

Active side-flexion of the neck.

Passive side-flexion of the neck.

Resisted side-flexion of the neck.

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localized contractions of muscle fiber or trigger pointareas (a secondary phenomenon). When the primarysource of the referred pain (the sacroiliac ligamentsprain) is eliminated and a full range of motion isreestablished, the trigger areas usually disappear bythemselves. In some cases these secondary trigger areasdo not disappear, and must be eliminated by hands-ontreatment. This is especially common in cases where thereferred pain has been present for a long time. In mywork with clients, I’ve found that when trigger areas aretreated without treating the primary source of the pain,the relief is temporary and localized, and the pain quick-ly returns—usually within a few hours or days after thetreatment. I have heard this scenario described by manytherapists I have trained in orthopedic massage.

In the course of my ongoing practice and research ofthis phenomenon, I have tested hundreds of clients fortrigger areas. In 95 percent of clients I see who have nopain problems at all, I can find hundreds of tense areasthat cause pain under pressure. When I began my workin this field forty-four years ago, I believed muscle ten-sion and trigger areas were the major causes of pain andinjury, but my training in orthopedic medicine changed

my thinking. While accumulated muscle tension in thebody makes it more likely that injury will occur, it usual-ly does not constitute a significant injury in and of itself.

For some readers, this alternative understanding ofthe trigger point phenomenon may make perfect senseand reflect your experience with clients. For others itmay seem like heresy and differ from your experience.Only time and further research will tell us what isactually happening and which theories will stand thetest of time and more scientific scrutiny.

Expanding Your Knowledge

Practitioners in all therapeutic modalities are subject tocertain biases in the way they approach assessment

and treatment—and massage therapists are no exception.In 1979, the study of orthopedic medicine helped showme the limitations of my own ways of thinking. HereI’ve used the principles of orthopedic medicine to chal-lenge what I see as five common misconceptions aboutpain and injury. I hope you will find this informationuseful in expanding your knowledge base and providingthe best possible care to your clients.

Ben E. Benjamin, PhD, holds a doctorate in education and sportsmedicine. He is senior vice president of strategic development for CortivaEducation and founder of the Muscular Therapy Institute. He has beenin private practice for more than forty years and is the author of Listento Your Pain, Are You Tense? and Exercise Without Injury andcoauthor of The Ethics of Touch. He can be contacted atbbenjamin@cortiva.com.

Notes1. Ludwig, Ombregt, Pierre Bisschop, and Herman J ter Veer, A System of Orthopaedic Medicine

(London:WB Saunders Company, 1995), 35.2. Ibid., 95.3. Ibid., 45.4. James Cyriax, Textbook of Orthopedic Medicine,Vol. 1 (London: Bailliere Tindall, 1984), 127.5.Thomas A. Dorman and Thomas H. Ravin, Diagnosis and Injection Techniques in Orthopedic

Medicine (Baltimore:Williams and Wilkins, 1991), 67.6. Ombregt et al., 7, 14.7. Ibid., 15.8. Ibid., 17, 18.9. Ibid., 8.

10. Ibid., 71.11. Leon Chaitow and Judith Walker DeLany, Clinical Application of Neuromuscular Techniques,Vol.

1:The Upper Body (Edinburgh: Churchill Livingstone, 2000).12. Leon Chaitow and Judith Walker DeLany, Clinical Application of Neuromuscular Techniques,Vol.

2:The Lower Body (Edinburgh: Churchill Livingstone, 2002).13. David G. Simons, Janet G.Travell, and Lois S. Simons, Myofascial Pain and Dysfunction:The

Trigger Point Manual,Vol. 1:The Upper Half of Body (2nd ed.) (Baltimore:Williams and Wilkins, 1999).14. Janet G.Travell and David G. Simons, Myofascial Pain and Dysfunction:The Trigger Point Manual,

Vol. 2:The Lower Extremities (Baltimore:Williams and Wilkins, 1992).15. Chaitow and Walker DeLany, 2000; Chaitow and Judith Walker DeLany, 2002; Simons et al.,

1999;Travell and David G. Simons, 1992.16.The two previous paragraphs are adapted from Leon Chaitow and Judith Walker DeLany,

Clinical Application of Neuromuscular Techniques,Vol. 1:The Upper Body (Edinburgh: ChurchillLivingstone, 2000).

ResourcesChaitow, Leon, and Judith Walker DeLany. 2000. Clinical Application of Neuromuscular Techniques,Vol.

1:The Upper Body. Edinburgh: Churchill Livingstone.Chaitow, Leon, and Judith Walker DeLany. 2002. Clinical Application of Neuromuscular Techniques,Vol.

2:The Lower Body. Edinburgh: Churchill Livingstone.Cyriax, James. 1984. Textbook of Orthopedic Medicine,Vol. 1. London: Bailliere Tindall.Dorman,Thomas A., and Thomas H. Ravin. 1991. Diagnosis and Injection Techniques in Orthopedic

Medicine. Baltimore:Williams and Wilkins.Lewit, Karel. 1985. Manipulative therapy in rehabilitation of the locomotor system. London:

Butterworths.Ombregt, Ludwig, Pierre Bisschop, and Herman J ter Veer. 1995. A System of Orthopaedic Medicine.

London:WB Saunders Company, 1995.Simons, David G., Janet G.Travell, and Lois S. Simons. 1999. Myofascial Pain and Dysfunction:The

Trigger Point Manual,Vol. 1:The Upper Half of Body (2nd ed.). Baltimore:Williams and Wilkins.Travell, Janet G., and David G. Simons. 1992. Myofascial Pain and Dysfunction:The Trigger Point

Manual,Vol. 2:The Lower Extremities. Baltimore:Williams and Wilkins.Yates, John. 1990. A Physician’s Guide to Therapeutic Massage: Its Physiological Effects and Their

Application to Treatment.Vancouver: Massage Therapists’ Association of British Columbia.

M&B

Only time and further research will

tell what is actually happening and

which theories will stand the test of

time and more scientific scrutiny.

A U G U S T / S E P T E M B E R 2 0 0 6 • M A S S A G E & B O DY WO R K 125