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6 tales of blood clots dangerously dislodged by massage

 •  • by Paul Ingraham
Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

My article about the effect of massage on circulation explains the need to be careful with dislodging blood clots. A professional massage therapist read this and asked me:

“Do we actually have known cases out there? Cases where massage has actually physically moved blood clots?”

Oh dear me yes indeedy. It isn’t common, but it absolutely happens.

I had citations to three case studies, but they were curiously missing from the circulation article and were used only in another article dedicated to massage side effects and harms. This is the kind of thing that keeps me busy! Obviously I needed more citations, cited in both places, and — ideally — I needed to summarize them nicely, because case studies are stories, and stories have a unique power to move our minds.

It got quite interesting. I thought sharing those stories would make for a fine addition to the blog. So here are six summaries of six case interesting tales of dislodged blood clots causing pulmonary emboli… all dangerous, some lethal.

A blood clot blocking circulation to branching downstream veins (purple), as occurs in pulmonary emboli.

An elderly woman developed a lung embolus after her husband vigorously massaged her leg, which had a known deep vein thrombosis — a serious contraindication to massage which any competent massage therapist would certainly avoid.

But not all of them…and not husbands as a general rule.

Details thin on this one. Source: Warren 1978

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“Massage” in the form of walking on the back (which is not as rare or necessarily as reckless as it sounds) dislodged a clot in the aorta at the site of an old graft. This is an unusual case, but not because of the massage, which is why they wrote it up: “It is controversial whether aortic occlusion can lead to retrograde thrombosis of the renal arteries.” But it appeared to in this case, and that’s what the report is focused on.

The graft “occluded over a year before admission but the loin symptoms only appeared after the massage. We presume that in this case in the presence of normal renal arteries the physical trauma led to dislodgement of thrombus…”

Does seem likely. Source: Mikhail 1997

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This letter to the editor of The American Journal of Physical Medication & Rehabilitation describes a case of a 53-year-old woman with progressively worsening shortness of breath, which started after a “vigorous” massage of her calf muscles at a pedicure shop. She had “filling defects” in “several” lung arteries. She survived this: the emboli were successfully dissolved by anti-coagulants. But a close call for sure.

The authors opine: “Not only can [massage] dislodge an already established blood clot, but, as in this case, it can also predispose an individual to venous thrombosis and subsequent pulmonary embolism. … there is likely underreporting.”

Source: Jabr 2007

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A man had a deep vein thrombosis that was presumably caused by a long-haul flight — flex your ankles regularly on flights, folks! He was treated with anticoagulants for months, but the clot remained…

Until it was dislodged in a massage two years later. The massage was a “full-body” massage and included the legs, but no other details were noted. “The onset of dyspnoea soon after leg massage suggests that this was the likely cause of thrombus embolisation.” His only symptom was shortness of breath, which is impressive considering how serious the embolus was.

It was a “worm-shaped right atrial embolus, most probably a femoral cast.” Meaning the embolus was basically the shape of the vessel where it had lived until it was dislodged, and wormed its way into a lung.. •shudder

Source: Lim 2009

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This is case study of a young man who died because his mother gave him a leg massage after an ankle fracture. I’ll just quote the paper in this case:

“Autopsy confirmed the cause of death as pulmonary thromboembolism due to deep vein thrombosis of the leg veins which was dislodged and travelled to his lungs consequent to the leg massage. The treating doctors did not warn the patient of the risk of developing pulmonary thromboembolism.”

Source: Behera 2018

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And now for the worst and most recent:

A pregnant woman fell into a coma after a traditional Thai massage at a shopping center in Chiang Mai, Thailand. Her baby miscarried. The cause was a clot in her leg, which was dislodged and carried to her lungs, where it stuck, cutting off lung circulation.

About 10 minutes after her massage, the woman developed shortness of breath, became disoriented, convulsed, lost consciousness, and had a heart attack. She was initially resuscitated at the hospital, but remained comatose, and she remained unconscious for two months until the case report was written.

“Pregnant women are at a higher risk of undetected or subtle thromboembolism…” and “it is reasonable to conclude that the patient had undetected preexisting deep vein thrombosis, which was mechanically dislodged by the massage and travelled massively to both lungs, leading to a life threatening condition.”

Source: Sutham 2020

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And, yes, these are all now cited in the two main places they should be:

“Objection! This has nothing to do with real/competent massage therapy”

This objection is cropping up quite a bit on social media. I should have seen it coming, but I didn’t.

I am afraid these horror stories really do have something to do with massage therapy. (It also doesn’t have to be about “real” massage therapy to be useful information.)

Yes, competent and well-trained therapists are aware of the risks of massaging someone at high risk for DVT. Congratulations. Now, if you are one of those therapists, how about amplifying it for the junior and lesser-trained therapists who need the information? Why would a competent massage therapist object to promoting awareness of a serious safety issue in their profession? More information is good!

Not all massage therapists are competent and well-trained. And even competent and well-trained massage therapists may not be as aware as they could be. Remember, this post was inspired by a question from a professional massage therapist who did not know that this was possible. Many other massage therapists have asked me similar questions, clearly indicating that they do not understand the biology and the risks well. (This follows from the prevalence of anti-scientific and magical thinking. When people believe in energy medicine, they aren’t going to be as interested in the real kind.)

In any case — even if massage therapists are so awesome that they don’t need any reinforcements of their education, ever — this also useful safety knowledge for non massage therapists who love massage and perform self-massage and partner-massage.

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