As a massage therapist, your hands are the tools of your trade. They are quite literally your money-makers. Any therapist who has injured a hand or arm knows how important the thumbs are to a massage career. Yet, many massage therapists who do clinical work are damaging their hands every day by overusing their thumbs.
Let’s be clear: Every activity causes wear and tear on the body. If you do anything enough times it will cause changes in the body and potentially damage it. That said, overuse injuries of the hand are extremely prevalent in massage therapists and cause many therapists to burn out.
Tendinitis, tendonosis, osteoarthritis and trigger finger are just a few of the ways in which massage can injure the hands. Further, osteoarthritis in the interphalangeal joint, the metacarpal phalangeal joint and the carpometacarpal joint of the thumb are the most common issues caused by overuse of the thumb. Many massage therapists also develop tendinitis in the flexor and extensor muscles of the thumb.
We know that overusing the body is going to damage it over time—so how do you extend your career and protect your tools?
The answer: less thumbs.
Many massage therapists—experienced and new—consider themselves a “thumb specialist.” These therapists do the bulk of their work with the thumb. Stacking the joints, a popular form of body mechanics, is great; however, even with this technique you are still putting a significant amount of pressure on the small joints of the thumb. These joints are ideal for delicate, fine movements with great sensitivity—but not for heavy, sustained pressure, day in and day out.
One reason many massage therapists continue to overuse their thumbs is they feel like they have better sensitivity when using their thumbs. (This is a valid point when doing, for example, trigger- point work.)
A large part of this sensitivity is due to familiarity. If you are used to using your thumbs it will feel awkward to use other parts of the hand or arm. This will pass with practice. You can still use your thumbs; I often use them to locate a trigger point, for example, then switch to another tool for compression.
Many massage therapists who injure their thumbs repetitively end up using a thumb-saver type of tool to keep working. But can you feel more through an artificial tool or through another part of your hand?
Let’s talk alternatives. If you want to minimize the use of thumbs during massage, you need to incorporate a wide variety of other bony parts of the hand and arm. Which tool you use will be determined by the size and shape of the area of the body you are working on. Everyone is different, and the best tool is the one that fits the space the easiest and allows you to spread the work over a variety of tools.
Proximal interphalangeal joints. The proximal interphalangeal joints of fingers two through four are a great alternative to always using the tip of your thumb. You can use the second finger’s proximal interphalangeal joint on small areas of your clients like the neck, occipital region, hands and feet.
I often use all four proximal interphalangeals on both hands simultaneously to pull up the posterior neck muscles while the client is supine. On feet, I use all four proximal interphalangeal joints of one hand to strip down the sole of the foot for flexor digitorum brevis and quadratus plantaris.
For cross-fiber techniques on larger areas, like the erector spinae group, you can also use all four proximal interphalangeal joints at the same time. You can use both hands side-by-side to work a really large area at once. You can use a proximal interphalangeal joint nearly any time you would have used a thumb.
Metacarpal bones. The heads of the metacarpal bones are also wonderful alternatives to thumbs. Specifically, the secondand fifth ones—on the index and pinky fingers—respectively. These can be used to work a variety of areas of the body.
The head of the fifth metacarpal can be used to work large areas such as the erector spinae group and the quadratus lumborum as well as the gluteal muscles and hamstrings, while also being useful for smaller areas such as the soles of the feet and palms of the hands. You can also use it to work the teres major and minor as well as the triceps brachii.
There is a technique in tui na called rolling that utilizes the fifth metacarpal head and is my go-to technique for avoiding overuse of the thumbs because it works for so many areas of the body. The second metacarpal head can be used to work the neck region in a supine position, including working the suboccipitals, splenius capitis, trapezius and levator scapula muscles.
The heads of metacarpals two to four can be used together to strip longitudinally down large, long muscles like the erector spinae. I often do this bilaterally, using both hands at the same time. These heads can be used for cross-fiber manipulation or for trigger-point work.
The key to using the metacarpal heads is to hold a relaxed fist. If the fingers are relaxed they will move out of the way so the pressure can be applied directly with the head of the metacarpal without straining the extensor digitorum muscle.
Pisaform bone. One of my favorite thumb replacements is the pisiform bone. This carpal bone is small, hard and easy to use. Anywhere there is enough room for your hand—such as the shoulder/pectoralis region, the back and thighs—is a great choice for the pisiform bone.
The trick to safely using it is to allow the whole hand and wrist to make contact while concentrating the pressure through the pisiform itself. This way, you do not injure the extensors lifting the hand off the surface but the pressure is still through this small carpal bone.
The pisiform bone is wonderful for rhythmic compression on a region. You can easily focus pressure just on the pisiform or spread it out on the whole palm.
Caution should be used with this technique so pressure isn’t applied over the carpal tunnel excessively. Otherwise, you run the risk of irritating it.
Forearm and elbow. Another effective way to avoid overusing thumbs is to use the forearm and elbow, more properly the ulna and its olecranon process. Massage therapists often will use the ulna to work broad areas such as the back. The forearms work well for the lumbar region as well as the entire erector spinae group. The ulna can be utilized to work long muscle groups such as the quadriceps muscles of the thigh quite effectively.
I often treat the flexor and extensors of the forearm with my ulna. Often the olecranon process is used to work with heavier pressure, such as when working the deep six lateral rotators of the hip, including the piriformis muscle. It is also commonly used, and works well for, the upper trapezius muscle; however, consider that the olecranon process is a rather small protuberance and can be used for more detailed work such as the flexor and extensor groups of the forearm or the feet.
Don’t be afraid to try using your elbow in unusual areas. One place the olecranon works surprisingly well is the suboccipital-and-cervical region.
All of this isn’t to say you should never use your thumbs; in fact, the thumb is a wonderful tool for very precise, delicate work. I use my thumbs for bodywork on the face, and also to work the scalene muscles. There are certain techniques on the hands and feet where the thumb is ideal. I utilize my thumbs for grasping techniques on the neck and extremities.
The goal is simply to minimize the unnecessary use of the thumbs. If another tool works as well or better, choose the other tool. When nothing else works better, use the thumb.
I try to keep use of my thumbs to no more than 10% to 15% of a session—because the key to a long, healthy career in bodywork is protecting your money-makers.
About the author
Nate Novgrod, MAcOM, Dipl. Ac. (NCCAOM), LAc, 4th Duan, is a licensed acupuncturist and educator. He runs Waynesville Wellness and also teaches continuing education courses for acupuncturists and massage therapists. He trained at the Oregon College of Oriental Medicine. His courses for massage therapists are approved by the National Certification Board for Therapeutic Massage & Bodywork. He has studied tai chi for more than 23 years.
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