Most of us are familiar with the saying “no pain, no gain!”

But what does that mean in reference to massage? Is it about deep pressure, deep tissue? Are the two even equal? Is there a cost to a “no pain no gain” mentality? How deep is a deep tissue massage supposed to feel anyway?

There is a large misconception that “no pain, no gain” is a necessary evil in the soft tissue world. The reality is quite the opposite. Let’s look into what creates tissue damage and the differences between deep tissue and deep pressure.

Education time! What is Tissue Loading?

Before we can compare and contrast ‘deep tissue’ versus ‘deep pressure’, we need some background info on what causes tissue damage. Tissue, here, means muscles, tendons, ligaments, and fascia.

Now, there are 5 types of excessive force loading that injure soft tissue:

  • Shearing
  • Bending
  • Torsion
  • Compression
  • Tension
Types of Tissue Loading

Compression

  • When an external force between two surfaces becomes excessive, the lesser load becomes compacted.
  • This shortening and widening of the weaker structure cause fiber disruptions and intramuscular bleeding.
  • This typically results in bruising with possible spasms and limited movement on the closest joint.
  • Constant repetitive compression can weaken the tissues and cause injury to more readily occur.
  • Contusions, fractures, and arthritic changes in cartilage are common from this type of loading.

Tension

  • A force that causes pulling and stretching along the underlying fiber direction.
  • Excessive tensile forces can lead to acute rupture of the muscle belly fibers or the collagenous material in the tendon or ligament.
  • Usually from weight-bearing or overexertion, repetitive stress.
  • Overuse syndromes, muscle strains, and ligament sprains derive from this force of injury.
  • These injuries are more readily identified as “repetitive stress injury/fatigue”, or technically speaking “repetitive submaximal stress.” 

Bending

  • When a structure is loaded in bending, compression forces at opposite ends of a structure push toward one direction subjecting a tension force on the convex (overstretched) side.
  • Excessive bending can result in a snap.
  • These injuries are typically seen in long bone fractures and ligament sprains.

Shearing

  • When opposite but parallel sliding loads are applied through inertia or gravity, fiber destruction can occur.
  • Think about how you get rug burns or scrapes: one seemingly smooth surface (skin is porous) trying to glide on a tougher grittier surface (asphalt, or any material carpet that you roll around on with kids or pets or friends).
  • This can cause obvious skin injuries (inflammation, abrasions, blisters) or less obvious vertebral disk injuries, even muscle sprains or subluxations and dislocations.

Torsion

  • A combination of shearing, tension, and compression forces.
  • This combined loading creates a twist in opposing directions on different ends of a structure. 
  • Spiral fractures and disk herniations tend to result from this type of loading.

WHEW, that’s a lot of jargon!

If you really sit down and think about the movements your massage therapist uses during your session, it will dawn on you that they use a variety of these forces throughout your manual therapy work.

  • Deep transverse friction is a tension force. 
  • Cross friction is a form of shearing. 
  • Petrissage (a French term meaning “to knead”) is a torsion force. 
  • Joint mobilization is a bending force. 

All of these common techniques utilize LOADING FORCES.

How Does a Massage Therapist Avoid Causing Tissue Damage During a Deep Tissue Session?

Certainly not giving in to the idea of “no pain, no gain”! At least not without a plan or awareness of the healing process in mind.

Acknowledging that we as therapists can potentially hurt another person despite our training is imperative to the quality of our work and the integrity of our character. There are times when a therapist is inexperienced or self-doubting that they surrender to a patient or a client’s statements of “you can go deeper if you want to, I can handle the pain” or “I know it’s going to hurt but that’s ok, go as hard as you want” without driving the conversation toward education. Sure, they might ‘feel better’ in 3 days when the inflammatory phase of the healing process mostly subsides, but doling out excruciating pain because “the customer is always right” can create very serious liabilities for the therapist and risky side effects to the client.

Without proper ongoing care through the subsequent regeneration and remodeling phases, utilizing intense pressure haphazardly will edge the receiver of the massage closer toward chronic dysfunction, compromised tissue durability and elasticity, and possible nerve injury.

A true deep tissue massage is slow, focused, and formulaic. A competent therapist will zone in on the problem area, locate relevant knots and tense tissue bands, adjust their pressure based on client reaction (without forgetting to ask the client to speak up if they experience severe pain), and work dermal layer by fasciae layer by muscle layer in multiple directions to alleviate the tension.

The most commonly used techniques for deep tissue include skin rolling, concentrated compressions, the squeezing and stretching of muscle bellies (petrissage), cross-fiber friction, and usually ending with elongated sweeping motions for a smidge of relaxation—a nice sweeping conclusion to a rather serious massage.

This form of therapeutic touch addresses at most two areas of concern (depending on the length of the session) and is rarely a full-body service. Whether or not you are prone to bruising, there shouldn’t be much as an outcome of this modality although I would anticipate a bit of soreness that lasts no longer than 2 days.

Where Does Deep Pressure Come Into Play Then?

In this past near-decade of my career, I have found that most people who are looking for deep tissue massage are actually looking for deep pressure.

Deep pressure is more of an “I can’t wait for this massage to be over” or “I might end up in the hospital soon” type of pain. It’s an UGLY pain when the pain should be more along the lines of “it tickles and hurts at the same time” or “hurts so good.” Dull, warm pain is preferable over hot, sharp, crushing pain.

It seems that these patients or clients with a ‘time to get roughed up’ mentality are seeking a physical sensation to resolve a psychological need—it’s a way of granting emotional catharsis through physical overstimulation. Or, to absolve the on-and-off pain that haunts their daily wellbeing and quality of life, they believe that by increasing pain excessively then it will. For a while, maybe so!

In the long run, those soft tissues only become weaker and weaker over time, leaving you vulnerable to lingering injuries and infection (because necrotic/dead soft tissue creates a risk for infection!). Over-sensitizing a nerve repeatedly and asking for “more, more, more” leads to gradual nerve damage—and nerves grow back at about 3-4 millimeters per year! How much of our body are we asking for deep pressure on and how often?

Additionally, when we brace ourselves in anticipation of the pain our muscles will naturally push back against the intense pressure. If the knots can’t relax then the tissue can’t heal, and if all we’re doing is tricking your brain into believing that the body is feeling better then how long before we’re asking our therapist to use all of their body weight and more to give us “a feeling”?

There’s a time and a place for deep pressure, usually with a trained professional who possesses the knowledge of nerve and vascular bundle placements to avoid adverse side effects or long-term injuries.

A great example of good deep pressure is active release technique (or ART for short) which we offer in the office. ART requires active movement and a deep level of pressure to break up underlying adhesions or scar tissue to increase flexibility and mobility. This modality can result in soreness and possible bruising. Contact us if you’d like to know more about what we have to offer.

Don’t hurt yourselves! Too much of what seems like a good thing can be detrimental to our overall well-being.

-Lex Alvarado CNMT, CAMTC

Lex Alvarado has over 14 years of experience working with patients, collaborating care to improve pain and posture. 
She is certified in Active Release Technique (ART) and neuromuscular massage (CNMT) and is a Board certified massage therapist (CAMTC).