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Can massage treat tendinitis?

Can massage treat tendinitis?

Deep Friction Massage Therapy for Tendinitis

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

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

If you have tendinitis, or a closely related problem, you may be able to accelerate healing with a self-massage technique called “frictioning” or “deep friction massage.”1 This has been a popular and widely used treatment method for decades now.2 It’s efficacy is unproven and it is effectively still experimental,3 but it may be appropriate to use in cases of:

Friction massage “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.4


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

About “tendinitis” versus “tendonitis”: Both spellings are considered acceptable these days, but the first is technically correct and more formal, while the second is an old misspelling that has only achieved respectability through popular use. The word is based on the the Latin “tendo” which has a genitive singular form of tendinis, and a combining form that is therefore tendin. (Source: Stedmans Electronic Medical Dictionary.)

How to do friction massage

The method is inconsistent in the wild.5 I will try to provide some guidelines that split the differences. Friction massage is distinctive — it has a different goal and feel than the more typical squeezing and steam-rolling of muscles, as you might do with some tennis ball massage. But the action of friction massage is simple and well-suited to self-treatment, as long as you can reach the problem (and most tendinitis 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 tendinitis, 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 tendinitis. If it is too painful, either you are pressing too hard, or the tendinitis 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.


How friction massage works (if it works)

Friction massage is in theory a very specific way to “use it or lose it” — to stimulate enough, but not too much.

A basic principle of healing is that overloaded tissue must be given a bit of a break from their labours, and this is particularly true of tendinitis, where stress has already exceeded the capacity to adapt. Equally true, total stagnancy is just as bad, and some stimulation is a vital component of tissue health and healing. This is the concept of “hormesis[Wikipedia]: tissue is hurt by too little or too much action.

A sick tendon needs at least some moderate stimulation in order to move tissue fluids and to induce connective tissue repair. But what kind of stimulation, if you’re trying to avoid pulling it?

In the case of tendinitis, excessive pulling on the tendon is the most common cause of the problem in the first place. If this is the case, more pulling may be counter-productive. The friction massage technique is a way to stimulate the tissue in a new and different way. For whatever it’s worth, that’s the big idea: get the benefit of stimulating the tissue without any more longitudinal loading.

That’s a simple explanation for the usual rationale for this treatment. And I am not endorsing it — I’m just reporting it. That’s the conventional wisdom. What else might be going on?

What if tendinitis is about over-squished tendons, not over-pulled?

Not all tendinitis is necessarily about too much pulling (longitudinal forces). In some cases, the nature of overloading may be compression of the tendon as it is pinched against bone, like a bungie cord flattening when pulled taught around a corner.7 This probably occurs mostly where tendons attach to bones (insertional tendinitis) — for instance, right on the back of the heel where the Achilles tendon attaches, rather than the long skinny part higher up. In such cases, the tendon may be just as irritated by sitting/lying on it as by pulling.

If that’s so, does applying pressure make any sense? Maybe not! Frictions could be counter-productive.

On the other hand, a hypothetical partial compressive factor in some tendinopathy doesn’t seem like a deal-breaker to me. I doubt that frictions constitute the same kind of mechanical force as, for instance, lying or sitting on the afflicted tendon in gluteal or hamstring tendinopathy. A little brief gentle strumming ≠ sustained bodyweight compression!

Placebo?

Maybe the only way tendon friction is doing any good is by convincing people that it’s doing any good — a placebo. Manual therapy is an rich source of placebos, because hands-on attention is a great way to boost the perceived value of the treatment — and all the better if it’s a little uncomfortable. Slightly painful treatment must be “extra strength,” right?

Comic strip of a man standing in front of shelves full of bottles and boxes. On the left, the products are labelled “Placebos.” On the right, they are labelled “Fast-acting, extra-strength placebos.” The caption: “Hmm, better go with these.”

Cartoon by Loren Fishman, HumoresqueCartoons.com.

I don’t know if frictions are just a placebo delivery trick, but it’s well worth bearing in mind.

Diffuse noxious inhibitory control?

To some degree you can temporarily treat pain by “distracting” the nervous system with a new pain. (Squirrel!) In short, pain can inhibit pain. Diffuse noxious inhibitory control (DNIC), AKA conditioned pain modulation, is a kind of “stupid human trick,” a fairly well understood neurological effect.8 Although it is not a placebo, it is a very common way to give a boost to a placebo in any no-pain-no-gain treatment. If a treatment hurts little, it can temporarily ease whatever pain you started with… which can very strongly increase the belief that the treatment worked, and therefore a robust placebo effect.

So that’s going to be a factor in painful frictioning to at least some degree. Of course, frictions are not supposed to be painful! But not everyone agrees…

Breaking some eggs to make an omelette?

You could also describe (and do) frictioning more aggressively as a form of provocation therapy — hurting to help, breaking down to rebuild — 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 (really). See Tissue Provocation Therapies.

Friction massage can certainly be done 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 an interesting reason.

Chronic tendinitis 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.910

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?

Emphatically not — there is hardly any scientific research about friction massage at all, just a few slightly encouraging scraps.11 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.12 The technique remains mostly based only on speculation about the biology of rubbing. 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?

Some minor ones. There are only health risks if you are a bit reckless with it.

If you ignore excessive pain, you might accidentally attempt to friction massage something that isn’t tendinitis, and perhaps something that’s more vulnerable than tendinitis. 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.

Otherwise, the worst case scenario for self-treatment 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 tendinitis, unfortunately there are many conditions that get mistaken for tendinitis, and will therefore not be helped by friction massage.

If you pay a professional to do friction massge to you, there’s also a risk of wasting your money. In principle, I think friction massage is too sketchy to justify paying for it. In practice, it’s probably not a time-consuming enough procedure to be of much concern (compared to many other much more expensive/recurring treatments). A brief paid experiment might be appropriate for some desperate patients who can readily afford it. But the aggregate cost, for all patients over time, for a treatment that is basically just an educated guess… that’s a little worrisome. Professionals should do the big picture math and ask themselves if they want to be selling shots in the dark.

Tendinitis-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 tendinitis, 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.13

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

Tennis elbow may or may not be a “true” tendinitis, despite appearances. Myofascial pain syndrome (muscle knots) in the forearm is much more common than true tendinitis, and yet causes extremely similar symptoms. The main difference is a subtle difference in location and “hotness” and “sharpness” of the pain. Tendinitis 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 mileage with friction massage will vary — it may work well, or it may not work at all.

Plantar fasciitis, a common kind of pain in the arch of the foot, is another complex condition that is sort of like a tendinitis, 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!

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 tendinitis. Don’t be fooled! Surprisingly intense muscle pain is a much more common phenomenon than tendinitis (and tendinitis isn’t exactly rare). At their worst, muscle knots can be extremely painful and seem very, very much like a tendinitis. However, most muscle knots can’t hold a candle to the hot, burning intensity and extreme sensitivity of a tendinitis.

A true, acute tendinitis 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 tendinitis, 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…

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. 174 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

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. 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 or Twitter.

What’s new in this article?

OctoberThree small new sections added to the discussion of how frictions allegedly work: compressive tendinopathy, placebo, and diffuse noxious inhibitory control. I also now clearly state that I have described the rationale for frictions, not endorsed it. Added a recommendation not to pay for frictions. There is a skeptical theme to today’s updates. 😉

SeptemberCited Chaves on the prevalence of friction massage and inconsistent technique; a few minor related edits.

Notes

  1. Hertling D, Kessler R. Management of common musculoskeletal disorders. 3rd ed. Lippincott; 1996.

    An excellent technical overview of friction massage for professionals.

    BACK TO TEXT
  2. Chaves P, Simões D, Paço M, et al. Cyriax's deep friction massage application parameters: Evidence from a cross-sectional study with physiotherapists. Musculoskelet Sci Pract. 2017 Sep;32:92–97. PubMed #28934644. This paper reports use of friction massage by almost 90% of 478 surveyed physical therapists. That’s really high. BACK TO TEXT
  3. Which is true of nearly everything in the world of manual therapy (see papers like Machado, or my explanation of the problem of “pseudo-quackery” in physical therapy). This isn’t an excuse — that’s just how it is. More on the scanty evidence below. BACK TO TEXT
  4. When choosing treatments, please be wary of Quackery Red Flags: 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
  5. Chaves 2017, op. cit. “Our results have shown that the application parameters are heterogeneous and diverse.” BACK TO TEXT
  6. Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed. 2000;28(5):38–48. 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
  7. Cook J, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012 Mar;46(3):163–8. PubMed #22113234.

    From the paper’s conclusion: “Although the science is incomplete in substantiating a role for compression in the typical tendinopathies encountered in clinical practice, we have endeavoured to provide a cellular, biomechanical and clinical level for such a hypothesis to improve understanding and management of tendinopathy.”

    BACK TO TEXT
  8. Le Bars D, Villanueva L, Bouhassira D, Willer JC. Diffuse noxious inhibitory controls (DNIC) in animals and in man. Patol Fiziol Eksp Ter. 1992;(4):55–65. PubMed #1303506. BACK TO TEXT
  9. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed #20961685. PainSci #54851.

    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 much more detailed summary of this paper, see Central Sensitization in Chronic Pain.

    BACK TO TEXT
  10. PS Ingraham. Pain is Weird: Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it. PainScience.com. 10742 words. BACK TO TEXT
  11. Joseph MF, Taft K, Moskwa M, Denegar CR. Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. J Sport Rehabil. 2012 Nov;21(4):343–53. 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
  12. “Absence of evidence” instead of “evidence of absence.” There are many bogus treatments that have been studied intensely for decades, never yielding convincing positive results. This is not the case here. It’s just virtually ignored scientifically. BACK TO TEXT
  13. Loew LM, Brosseau L, Tugwell P, et al. Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Cochrane Database Syst Rev. 2014;11:CD003528. PubMed #25380079. BACK TO TEXT