Originally published in Massage & Bodywork magazine, February/March 2005.
Copyright 2005. Associated Bodywork and Massage Professionals. All rights reserved.

I am often surprised by the perceptions and occasional trepidation of students beginning a series of deep tissue massage or myofascial release classes. They are hungry for new skills and theories to increase their effectiveness and to prevent overuse injuries. Yet, they often express reservations about their fears of redefining their practice to only perform "therapeutic" deep work, or exhausting themselves by working "hard," or of causing their clients pain as they visualize getting a running start from across the room to land with their elbows.

Even experienced therapists may have had little or no training in the basic use of the tools of deep myofascial work. Although a necessity for deep tissue work, these tools are equally effective for more superficial, relaxation-based massage. In fact, I purposely refrain from defining "deep tissue" work because of the either/or mentality of categorizing work as one or the other. In reality, a therapist should be able to slow down and work deeply any time localized tension is encountered -- even in a nurturing, relaxation-based massage.

Knuckles, fists, forearms, and elbows need not be associated with deep, painful, or intense work. In fact, painful work is usually ineffective because the muscles contract against the pain, instead of lengthening and relaxing. The tools of deep tissue massage can be compared to the gears of a car, offering more efficient and versatile options to accommodate for speed, terrain, and whatever purpose you have. The intensity and depth of your massage work are dictated by how much you press the accelerator, rather than your choice of tools.

Beginning students are most comfortable in learning the complex concepts of touch with their hands, and of course it would be foolish and dangerous to prematurely teach the use of powerful alternatives until basic massage concepts are practiced and refined enough for students to translate and expand their newfound manual skills to such versatile tools as elbows/forearms, fists, and knuckles. Some entry-level teachers even withhold these vital skills that would enable new therapists to work more effectively and with less risk of overuse injuries, as well as teaching them how to provide a more pleasing, pain-free massage. New students can develop a fear or hesitancy as teachers imply that elbows or knuckles are "forbidden fruit," similar to the parent saying, "Not now, dear, wait until you are older."

The problem with this approach is new therapists attempt to work more deeply by straining and using limited options. They are thrown into their practices with a sink-or-swim approach and are intimidated by the prospect of using deep tissue skills that would save their energy, prevent overuse injuries, and significantly improve the quality of their touch and the effectiveness of their work. Therapists may define and limit their practice by restrictions imposed in their early training and are, therefore, uncomfortable dealing with structural and therapeutic issues. Often they begin work in a spa, a chiropractor's office, or athletic setting that requires deeper work. They are presented with an unremitting queue of clients and become injured and burned out when they haven't been sufficiently instructed in the biomechanical benefits of using more efficient techniques.

Of course these techniques do enable deeper, more intense work within the framework of a proper structural or therapeutic philosophy learned in a continuing education format. But, without the tools to work deeply, therapists are often hesitant to explore and expand their work in the blossoming and more financially rewarding fields of structural integration (Rolfing, The Guild for Structural Integration, Hellerwork, and the work of Tom Myers, and other excellent teachers) or more clinical/therapeutic philosophies (Erik Dalton, Paul St. Johns, Ben Benjamin, Whitney Lowe, orthopedic massage, and many others). It's a bit of a "Catch 22": Therapists are hesitant to aspire to the advanced training by excellent teachers because they lack the specific tools and confidence required to learn the work, but, because they don't do the work, they don't feel the need to learn these manual skills.

Once therapists become more proficient at using elbows, knuckles, fists -- even in a primarily relaxation-based practice -- they often become intrigued by the possibilities of expanding their focus to work more deeply in a structural setting or solve the everyday problems their regular clients present. Proper training in safety is essential, and more therapeutic and structural goals are best taught in a continuing education program with supervision.

The purpose of this article is not necessarily to transform your practice into performing exclusively deep work, but to simplify and enrich whatever work you do by expanding your options. Even advanced practitioners and physical therapists often don't utilize to their full advantage the options that knuckles, fists, elbows, and forearms afford, or they may not use these tools with efficiency. This article will emphasize the mechanics of these tools, while two subsequent articles will focus on utilizing these skills in the context of specific strategies and problem-solving.


Proper Use of the Knuckles
Overuse injuries to the thumbs can end your career as a massage therapist. For some strokes, the thumbs are indispensable, but for the majority of massage, knuckles are equally effective and often a preferable alternative. Let's examine the mechanics of proper knuckle use on the back and then demonstrate some examples of their use in other areas that can dramatically reduce your reliance on thumbs. A note of caution: Students are often so excited with the effectiveness that they transition from thumbs to knuckles too quickly and experience soreness. If you have not been using knuckles, begin slowly until your joints can adapt to the pressure.

Technique photos by David Booth.

The Back. Proper mechanics are crucial. It is imperative the fingers be extended in a straight line at the joint between the metacarpals and phalanges. Notice that the wrist is always used in a neutral position, and the elbow is relaxed, but extended, so force is supplied by gravity rather than muscular effort. The different lengths of the fingers necessitate the use of only one or two knuckles, and your height and distance from the client can control the angle for equal distribution of pressure between the knuckles. The key is to internally rotate your arm so that, for most strokes, your thumb will be down, this allows the wrist to be fixed in a neutral position. Strokes can be applied in a straight line, or rotation of the wrist, arm, and your entire body can approximate the kneading of thumbs.

The Ankle and Lower Leg. If you begin to use your knuckles on the hands and feet, you can cut your thumb use by 50 percent. In the supine position, utilize the soft,f leshy aspects of the knuckles when working over bony aspects such as the ankle retinaculum or the tender aspects of the tibialis anterior. Notice the straight line of force through the wrist and the fact that the opposing hand is used to plantarflex the ankle to provide stretch to the tissue.

Plantar Surface of the Foot. When working with the plantar surface of the foot, the key is to grab and stretch the tissue rather than just knead or slide over the tissue because of excess lubrication. Where is the foot not moving properly and restricted by the plantar fascia? In this case, the other hand is flexing the toes away from the direction of knuckle force to increase stretch and free the joints of the forefoot and transverse arch. Notice that the elbow is braced against the thorax so that power is generated by simply leaning forward with your body weight, rather than by muscular effort.

The Hands. Knuckles feel wonderful on the hands and can provide more power than thumbs to release tension. Use your opposite hand to support the client's hand and stretch the palmar surface. Feel how the bones move in the hand and direct your attention to free that layer, as well as superficial tissue.

Knuckles vs. Thumbs. Most of us begin our careers by working on the trapezius and neck with the thumbs -- a fine tool when working on a few clients a week. But as you expand your client load, the cumulative strain on the thumbs can cause serious problems. Notice the strain at the wrist and the shearing force on the thumb.

I have always highly respected the work of Erik Dalton and asked him to comment on how the issues of "touch" are addressed in his classes (See "Experience Cannot be Taught" under Related Articles). Dalton feels thumbs are an excellent tool because of their sensitivity in palpation. I certainly agree, but caution that one must be judicious in their use -- saving them for times when they are the best tool for your goals rather than your major choice for indiscriminate work.

The Neck and Trapezius. Specific strategies for working on this area will be addressed in following articles, but a demonstration of the basic biomechanics will enable you to rest your thumbs now. Rest your hand comfortably on the table and keep your wrist and knuckles extended in a neutral position, working just as you would with your thumbs. Working unilaterally offers many more options for stretching muscles and mobilizing the joints than bilateral work on the shoulders. Your left hand is free to side-bend, rotate, and mobilize the neck while working. Clients love the precision in this work.


Proper Use of the Fist
The fist is very useful as a relatively broad surface for work on virtually any fleshy area of the body. For the work to feel good, the hand must be relaxed and not clenched with tension. For more specific force, you may focus force directly at the four joints at the junction of the metacarpals and the fingers. For a broader and more forgiving surface, the force can be distributed with the flatter surface provided by the first four bones of the fingers. As with the knuckles, the most important consideration for the fist is to be sure the wrist is in a neutral position and not in a position of flexion/extension or inversion/eversion. Any time your force is compromised through a joint that is not in neutral position, power is lost and risk of overuse injuries increases. Let's take a look at the most common errors when using the fist.

Improper Use of the Fist. The most common error is to have the palm down, which places the wrist in excessive extension. This is actually just utilizing the palm of the hand rather than the fist -- a fine stroke by itself, but would be better accomplished by extending the fingers so the hand is flat and the wrist is less extended. In the second example, the wrist is flexed and all the advantages of gravity and efficient use of power are lost. Rotating the arm so the palm is up, as demonstrated in the next examples, will enable significantly more power.

Proper Use of the Fist. When using the fist for long body strokes, it is important to be far enough away from your client so your arm is relatively straight. Force should come from your own body weight or horizontal power provided by the legs, rather than the shoulder girdle muscles. Notice that with the palm facing up with the thumb forward, the wrist is in a neutral position, and the hand and the thumb are relaxed for a softer but powerful touch. Strategies for body placement and release of muscles will be covered later, but notice by dorsiflexing the ankle with the use of his knee, the therapist can place the calf on a stretch to actually lengthen the muscle rather than just compressing it.

The Fist for I.T. Band Work. The fist is an excellent tool to soften and stretch the iliotibial (I.T.) band. Here, the elbow is flexed and braced against the hip so power is provided by the therapist's body weight transferred through the pelvis. Be cautious to not press directly into the femur, as with almost all strokes, sink to the level at which you feel tension and then stretch the tissue with oblique pressure.

The Fist for Pelvic Work. The fist is an excellent tool for work in any of the large muscles of the pelvis and for softening tissue along the iliac crest in either prone or side-lying positions. In the first photo, notice how bending the elbow when the table is too high places strain on the shoulder and elbow joints. The second alternative of climbing on the table and using your own body weight is much more efficient. If you are not comfortable resting your knees on the table, then the use of the forearm or elbow are alternatives for better use of gravity, but this may not feel as nurturing as the fist.


Proper Use of the Forearm and Elbow
The mechanics of the forearm and elbow are quite similar. The forearm is more useful for broad, raking strokes while the elbow is extremely effective for precise pressure or sinking through superficial tissue to contact deep areas, such as working with the piriformis through the gluteals. The lines of demarcation are not sharp, the higher you raise your hand to sharpen the angle at the elbow, the more precise your strokes will be as force is localized at the elbow. Also, rotating the forearm allows you the versatility of the soft inner surface of the forearm for areas like the ribs, or you may utilize the harder, boney surface of the ulna in fleshy areas such as the quadriceps. Often, when performing a stroke with the forearm, you will encounter resistant tissue and only need to slow down, shift pressure to the elbow for more precision, and wait for the softening. Both of these tools are effective for adaptation to your own biomechanics. When using your hands, fists, or knuckles, if you find yourself struggling because the table is too high, all that is necessary is to shift to the forearm or elbow to enable the use of your body weight instead of muscular force.

The Elbow for Detailed Work. Most of us have had practice early in our massage training using the elbow or forearm for broad work on the back with the client lying prone, but many people do not utilize the elbow's effectiveness for other areas of the body. The following photos demonstrate just a few of the uses of this versatile tool.
The elbow is very effective for working the borders of long muscles or tendons such as the Achilles tendon. Notice how placing the elbow in the crook of the thumb can provide stability and how the elbow can be used for precise and delicate work.

Proper shoulder function depends not only on the ability of the humerus to rotate in the glenoid fossa, but also the mobility of the scapula to slide freely over the ribs. The elbow is a perfect tool to free the scapula from tight muscles and fascia along its lateral border. Notice that the other hand is mobilizing the humerus by rotation in the glenoid fossa.

Not all strokes need to be actively moving. Waiting patiently at trigger points or for softening of large tendon bundles -- such as the attachment of the hamstrings at the ischeal tuberosity -- is a very effective strategy.

Body Positioning and the Forearm/Elbow. Specifics of positioning your client's body will be covered in a later article, but the following example demonstrates the advantages of the side-lying position. Placing your client in a c-curve or fetal position allows the spine to flex, placing the erector spinae muscles into a stretched position for release. The "window wiper" stroke allows for a pleasant, broad surface to lengthen the back muscles. Place your palm on the table surface and lean your body weight into your forearm to sweep it back and forth across fibrous areas. Placing your hand closer or farther from the body will enable you to utilize your energy for either broad strokes with the forearm or more precise focus with the elbow.

The Forearm and the I.T. Band. Use the fleshy inner surface of the forearm for sensitive areas like the I.T. band. It is crucial to sink to the level of tension and then work diagonally rather than pushing directly into the femur. In this example, the stroke direction is toward the hip while the opposite hand is stretching the leg past the midline to mobilize the hip joint and stretch the tissue away from the direction of force.


Using the Vocabulary
Remember that the tools of deep tissue massage are not limited exclusively to deep or structural work. A great many students, many who have specialized in relaxation-based massage for years, say that expanding their options of tools has made their gentle work more efficient, fun, and appreciated by their clients.

The tools of deep tissue massage are actually the vocabulary you utilize to express yourself and communicate your therapeutic intention to your clients. Having a broad array of strategies enables you to work efficiently with less wear and tear on your own body as you perfect your biomechanics and eliminate strain and excess work in your massage. As you work with more ease, the quality of your touch will be more nurturing to, and treasured by, your clients. In addition, having the precision to focus your energy with options -- from very localized application of pressure using the knuckles or elbows to the broad stretching of large fascial sheets with the forearm or fist -- will add clarity and diversity to your work.

Art Riggs is a Certified Advanced Rolfer who practices in the San Francisco Bay area and teaches at the San Francisco School of Massage. He is the author of Deep Tissue Massage: A Visual Guide to Techniques and the seven-volume accompanying video series. Visit his website at www.deeptissuemassagemanual.com.