Areas of Caution for Massage Therapy

Massage and other forms of therapeutic bodywork are generally safe therapeutic modalities with numerous health benefits. Massage therapy can reduce physical and mental stress, decrease muscle tension and trigger points, and increase range of motion and flexibility. But as with all therapeutic interventions and activities, there are some risks, even for healthy clients. One source of risk comes from the potential injury to structures in the body’s areas of caution.

What are massage areas of caution? Areas of caution for massage therapy, also called endangerment sites or endangerment zones, are areas of the body where delicate structures are located and are vulnerable to injury from massage and bodywork techniques. These areas apply to all massage clients. The types of structures that are vulnerable in an area of caution may include arteries, veins, nerves, bursae, lymph nodes or vessels, or small and fragile bones. Examples of areas of caution for massage include the popliteal space behind the knee, the anterior cervical region, and the axillary region.

This article was written to help students in massage therapy school as well as practicing massage therapists to better understand these vulnerable areas in order to reduce the risk of causing client injury. It is also intended to help massage students and graduates who are preparing to take the FSMTB Massage & Bodywork Licensing Exam (MBLEx).

***There is a 15-question quiz on massage areas of caution, or endangerment sites, at the end of this post to test your comprehension and recall of the content presented in this article. These quiz questions are similar in format and difficulty as what you can expect to encounter on the actual MBLEx.

Overview of massage areas of caution

Learning about massage areas of caution is one of the earliest topics discussed in most massage therapy training programs. It is important for new student therapists to learn which areas of the body must be treated especially carefully and skillfully in order to reduce the risk of injury to the client. As the Hippocratic Oath states, “First, do no harm.” These endangerment sites are often discussed in anatomy and physiology classes, as well as during the practical hands-on skills and techniques classes. On the FSMTB Massage & Bodywork Licensing Exam (MBLEx), massage areas of caution are covered in the pathology content area, along with contraindications and special populations.

Only a few locations of the body are an area of caution for massage that should be avoided entirely and are considered “off limits’. This is because these areas would be dangerous or inappropriate to massage (e.g. eyes). It is typically ok to proceed with light and careful massage therapy techniques for most of the vulnerable areas of the body, even the massage endangerment sites, as long as massage is indicated and no contraindications are present. In addition to using lighter pressure at endangerment sites, massage therapists should avoid using focussed pressure, and apply distributed or diffuse pressure instead. For example, do not use a thumb, elbow or tool to apply trigger point techniques at the femoral triangle or popliteal space. But effleurage or a gentle myofascial stretch using your palm should be ok. All practicing massage therapists and students should also have liability insurance, because injuries can occur even by experienced and careful practitioners.

Massage therapists must be particularly observant for signs of client discomfort when working at or near an area of caution. It is important to educate clients to give feedback at any point during the massage if they feel abnormal or uncomfortable sensations such as tingling, sharp or shooting pain, or burning sensations. This client education should also differentiate what is “good pain”, which commonly comes from a safe deep tissue technique, from what is “bad pain” which is unintentional and may cause unwanted tissue damage.

As mentioned above, another name for massage areas of caution is endangerment sites, or endangerment zones. These massage terms however are not the same thing as massage contraindications. Massage contraindications are pre-existing conditions in an individual client that require a massage session or treatment to be modified, or even withheld entirely, in order to prevent harm to this client or the therapist. Contraindications can be local, meaning that they affect only a small area of the body, or they can be systemic, which means that they effect the entire body. Massage contraindications can also be categorized as absolute or relative. Absolute contraindications require massage to be completely withheld. Relative contraindications, also called precautions, mean that it may be ok to proceed with therapeutic massage or bodywork if the treatment is modified to accommodate the individual client’s condition. Examples of contraindications and precautions for massage therapy include acute injury, illness, certain medical conditions, abnormal lumps, and infection. You can learn more about massage contraindications and precautions in our guide to massage contraindications.

Vulnerable structures of the body

The vulnerable structures located at massage endangerment sites / areas of caution tend to be superficial (close to the surface). Some structures are vulnerable because there are bones deep to the structure. This means that pressure at this location will compress the delicate structure between the therapist’s hand and the bone. An example of this situation is the common fibular (peroneal) nerve which wraps around the head of the fibula. There is little soft tissue cushioning at this location, so pressure here could damage this nerve.The following is a list of the types of structures are vulnerable at massage areas of caution.

• Blood vessels such as major veins and arteries are a massage area of caution. A good rule of thumb for massage therapists is to avoid applying pressure anywhere that you can feel a pulse. For example, massage therapists should monitor for a pulse when doing deep massage work at the psoas to avoid compressing the nearby arteries.
• Lymph nodes and lymphatic vessels are delicate structures that are often superficial, and vulnerable to injury. They are vulnerable mostly on the anterior side of the body, but also at the popliteal space on the posterior side of the knee.
• Nerves are vulnerable to injury and are slow to regenerate if they get damaged. Nerves of the body are at risk of injury in places in the body where they can be compressed or stretched.
• Small and fragile bones are vulnerable to breaking with heavy massage pressure. Examples include the temporal stylus, xiphoid process, and the floating ribs.
• Bursae. These small structures can be irritated with deep pressure, especially when a superficial bursa becomes compressed between the therapist’s hand/elbow and a bone (e.g. trochanteric bursa). An inflamed or irritated bursa (bursitis) could also be considered a local contraindication, depending on the severity.

Massage areas of caution for the anterior body

More areas of caution for massage are located on the anterior aspect of the body than on the posterior aspect. A thorough review of these areas of caution should be included in a massage student’s MBLEx study plan.

Vulnerable areas and structures of the head and anterior neck

• Eyes, face, forehead, temporal and TMJ area. Light massage techniques only at these areas. Structures that are vulnerable to injury at these endangerment sites include the facial nerve, the branches of the trigeminal nerve, temporal artery and parotid gland.
• Styloid process of the temporal bone. The styloid process is a slender bony projection that extends downward and anteriorly from the temporal bone, just below the ear. It is a massage area of caution because it is a small and fragile bone that can easily be broken.
• Anterior and lateral cervical region. The cervical region is an endangerment site that contains several vulnerable structures. It is sometimes referred to as the anterior triangle of the neck.
  • Blood vessels: common carotid artery and jugular vein. The carotid sinus is located where the common carotid artery divides (bifurcates) into the internal and external carotid arteries. The carotid sinus is a baroreceptor, which means that it detects blood pressure. Stimulating this baroreceptor can result in a dangerous drop in blood pressure.
  • Cranial Nerves, including the facial nerve (CN VII), glossopharyngeal (CN IX), vagus (CN X), accessory nerve (CN XI) and hypoglossal nerve (CN XII) are located at this area of caution.
  • Hyoid bone, which is the U-shaped bone at the superior aspect of the anterior cervical region, serves as an attachment point for the suprahyoid and infrahyoid muscles. This small bone is fragile and vulnerable to injury.
  • Other structures: thyroid gland and cartilage, cervical lymph nodes, trachea, submandibular glands.
• Sternal notch. The sternal notch is located superior to the manubrium part of the sternum. The nerves and blood vessels to the thyroid gland, as well as the vagus nerve and trachea are vulnerable here.

You can review a list of common massage abbreviations here.

Anterior upper extremity areas of caution

• Clavicle and surrounding soft tissues are an area of caution (no deep pressure). The clavicle is designed not only to provide a skeletal connection to the scapula and humerus, but to protect the vulnerable structures behind it, including blood vessels and nerves of the brachial plexus.
• Axilla and medial aspect of the upper arm. Brachial artery, axillary artery and vein, basilic vein, cephalic vein, lymph nodes, and nerves of the brachial plexus.
• Antecubital region, also called cubital or antecubital fossa. This area is located at the crease of elbow. Structures that are vulnerable here include the radial nerve, median nerve, and the brachial artery which divides here into the radial artery and ulnar artery.
• Anterior wrist. The radial nerve and artery, median nerve, ulnar nerve and ulnar artery are vulnerable at the distal radius and ulnar area. The radial pulse point, as with all pulse points of the body, are considered and area of caution for massage.

Learn muscles of the upper extremity here. This study guide reviews muscle groups, as well as the origins, insertions, action and innervation of all major skeletal muscles of the upper limb.

Endangerment sites on the anterior thoracic, abdominal and pelvic regions

• Anterior pectoral / deltoid region. The lateral component of this region merges with the axillary area of caution which contains the brachial plexus, axillary blood vessels, and lymphatic vessels and nodes.
• Breast tissue. This area is not normally treated during a therapeutic massage, however if the treatment plan does call for female breast massage (e.g. post-surgical scar reduction or impaired lymphatic flow), this is considered an area of caution, and should receive light massage techniques only.
• Xiphoid process. Like the styloid process of the temporal bone, the xiphoid process of the sternum is a small bony projection that can break if excessive pressure is placed on it. The xiphoid process is located at the inferior end of the breastbone.
• Ribs, especially the lower ribs (false ribs and floating ribs), are a massage area of caution. All of the ribs can be considered a local precaution (relative contraindication) for clients with osteoporosis due to the increased risk of fracture.
• Abdominal and umbilicus (belly button area) region can be massaged but should be done carefully, avoiding heavy pressure and working within the client’s comfort level. There are many vital organs, vessels and tissues located here that could cause serious harm if damaged. These structures include: abdominal aorta, inferior vena cava, vagus nerve, large and small intestines, stomach, liver, and gall bladder.
• Urinary bladder and pubic regions.

Anterior lower extremity endangerment zones

• Inguinal region and femoral triangle are located adjacent and inferior to the inguinal ligament at the anterior aspect of the hip joint. The medial border of this region is the adductor longus muscle, and the lateral border is the sartorius muscle of the thigh. The femoral triangle contains the femoral vein, artery and nerve. Other vulnerable structures located at the inguinal region are the great saphenous vein, the external iliac artery, and lymph nodes.
• Medial thigh contains vulnerable structures including branches of the obturator artery and common femoral artery, as well as the obturator nerve.
• Patella. Avoid excessive downward pressure on the patella (knee cap) which can cause a scouring action with the femoral condyles. Also avoid excessive medial or lateral patellar mobilization which can potentially cause a dislocation of the patella.
• Fibular head at the proximal end of the fibula bone is an endangerment site for the common fibular nerve (also called common peroneal nerve), which wraps around the head of the fibula.
• Medial and lateral malleolus regions are areas of caution primarily because of the surrounding sensitive areas and delicate structures (veins, arteries and nerves). The tarsal tunnel, just distal to the medial malleolus, is an endangerment site because the tibial nerve and posterior tibial vein and artery pass through it (along with some tendons). These tissues can easily be compressed and damaged with careless or excessive pressure.

Massage endangerment sites of the posterior body

The posterior aspect of the body contains fewer massage areas of caution than the anterior body. This makes sense considering that an instinctive defensive technique that humans and many other animals do when exposed to danger and threat of injury (for example a potential bear attack) is to curl up into the fetal position which protects the majority of the most vulnerable sites on the body. Massage therapists and students preparing for the massage licensing exam must have a thorough knowledge of the endangerment sites of the body before working with clients, especially if providing deep tissue massage techniques.

Vulnerable areas and structures of the posterior cervical region

• Posterior triangle of neck is actually located at the lateral aspect of the neck. It is bordered anteriorly by the sternocleidomastoid (SCM) muscle, posteriorly by the trapezius muscle, and inferiorly by the middle part of the clavicle. The posterior triangle contains vulnerable structures including the external jugular vein, subclavian artery and vein, the phrenic nerve (which innervates the diaphragm), the roots of the brachial plexus, lymph nodes, and part of the spinal accessory nerve (CN XI).
• Occiput and suboccipital area contain the occipital and suboccipital nerves, and the vertebral nerves and arteries. Since there are some very important structures here, massage therapists should avoid applying deep pressure here. Also, only use gentle amounts of force when assisting clients with upper cervical ROM stretches.

Areas of caution at the posterior upper extremity

• Cubital tunnel or notch at the posteromedial aspect of the elbow, is formed between the medial epicondyle of the humerus and the olecranon process of the ulna. The ulnar nerve passes through this tunnel and is vulnerable here. This is the nerve that is referred to as the “funny bone” when it is hit or irritated.
• Medial and lateral epicondyles of humerus should be treated as areas of caution due to the risk of compressing superficial tissues against these bony prominences.

Posterior thoracic, abdominal and pelvic areas of caution

• Ribs, especially lower ribs or floating ribs are an area of caution. Therapists must be particularly careful and gentle when working on any ribs of clients with osteoporosis. It’s good for massage therapists to periodically review the anatomy of the back muscles and other structures since this is an area that most clients want and need massage work.
• Kidneys at the lower posterior thoracic region (left and right) are delicate structures. Avoid tapotement / percussion techniques here, especially if using a mechanical percussive massage device such as a Massage Gun or Thumper.
• Coccyx (tailbone) is a small fusion of the most inferior vertebrae. The coccyx and its articulation with the sacrum is relatively fragile and vulnerable to injury from focal or excessive pressure.

Endangerment sites of the posterior lower extremity

• Greater sciatic notch of the posterior ilium which the sciatic nerve passes through.
• Greater trochanter could be considered an endangerment site because the bone is fairly superficial and the trochanteric bursa could be compressed and irritated if deep or focussed pressure is applied directly over the trochanter.
• Popliteal fossa at the posterior knee joint is an area of caution for massage due to the presence of the popliteal artery and vein, the tibial nerve & artery, and the common fibular nerve. There is also little protection for the internal structures of the knee here, such as the cruciate ligaments and meniscus, so deep pressure must be avoided.