Case Study: The Use of Swedish Massage to Manage Pain in a Client with Numerous Past Bilateral Injuries to the Lower Extremities

Abstract:

The overarching purpose of this study was to determine whether Swedish massage is an effective technique for managing and reducing pain in someone with multiple past lower extremity injuries. A 25 year-old male with a history of numerous traumas to bilateral ankles and knees received two 30 minute Swedish massage therapy treatment sessions, with primary focus on the lower extremities. Upon completion of these two treatment sessions, the 25 year-old client reported decreased pain on the Numeric Pain Rating Scale (NRS-11), and the massage practitioner made notes of improvements regarding posture, hip rotation, knee elevation, etc. Provided these results, Swedish massage appears to be an effective means of both managing and reducing pain when appropriate. 

Introduction:

A 25 year-old male, who has suffered numerous injuries to both of his lower extremities, volunteered for this study in which the effectiveness of Swedish Massage as a form of pain management was investigated. His past injuries included: a fractured left ankle, bilateral sprains to the knees and ankles in 2012, bilateral lateral patellar dislocation in 2016, a broken second metatarsal and phalange in the right foot in March of 2023, and sprained right ankle December 18th, 2023. At the time of the study, the client was under the care of a general physician, yet had not received any treatment for his latest injury. At this time, the client stated that pain he was experiencing spanned from his right ankle to the mid calf. Additionally, the client complained of a bilateral aching pain in his hips. Using the Numeric Pain Rating Scale (NRS-11), (Hartrick et al., 2003) the client reported having a pain level of five out of ten in his right ankle. His intent for  entering this study was to find a new technique for managing his recurrent and chronic pain.

The client suggested that typical management for the pain he experienced included use of medical devices that ultimately limited his range of motion and weight-bearing activity to the affected areas. In 2012, the client wore a boot for his fractured left ankle as well as an air cast for his sprained right ankle, both for six weeks. In 2016, he attended physical therapy for bilateral lateral patellar dislocation, and was wheelchair bound for a period of time, before transitioning to using crutches. Though he did see a doctor, he had no intervention for the broken metatarsal and phalange. As for the latest injury, the client said he attempted to stay off of his ankle as much as possible.  

In more recent years, Massage therapy has become more popular, especially as it focuses on specific, therapeutic work, as a means of addressing and managing pain. Patients who have experienced various health concerns causing them chronic pain are particularly provided with the proposition of seeking massage therapy. A literature review published by the National Institutes of Health in 2019, comprised evidence from 49 different authors who, through their own systemic reviews, identified Massage therapy as pain management. These individual studies highlighted techniques such as Swedish massage and relaxation massage specifically. It is worth noting, however, that the evidence supporting the idea that massage therapy is effective in managing pain, is limited as few high-quality studies include both large patient samples and rigorous methods  (Miake-Lye et al., 2019) .   

Swedish Massage is the most well-known form of massage practiced in the United States (Swedish Massage, 2019). Created by nineteenth century Swedish fencer, Per Henrik Ling, Swedish massage generally consists of  “long, flowing strokes, as well as kneading, tapping, and other rhythmic techniques” (Benson, 2019). It is most widely recognized for causing mental relaxation, easing muscle tension, and moving blood and lymph as each stroke has many benefits such as soothing of the parasympathetic and circulatory systems, increasing circulation, remodeling scar tissue, softening adhesions, and relaxing muscles. 

The objective of the client was to relieve pain in his right ankle and calf. The objective of the study was to determine the effectiveness of Swedish massage on managing and reducing pain in a client with a history of numerous injuries to the lower extremities, including: bilateral sprains and strains in the knees and ankles, bilateral lateral patellar dislocation, fractured left ankle, and a broken second metatarsal and second phalange in the right foot.

Methods:

Client Details

The 25 year-old client presented information regarding his history. In 2012, the client fell to the ground during a ropes course at his middle school, fracturing his left ankle and spraining ligaments in his knees and ankles bilaterally. He recalled spraining both of his medial collateral ligaments (MCL) specifically during this trauma. He wore both a boot for the left ankle and an air cast for the right ankle for a period of six weeks. In 2016, the client laterally dislocated both of his knees. The client could not recall a specific diagnosis, but stated that his physical therapist told him he had imbalanced strength in the muscles of his thighs, causing both of his patellas to be pulled laterally.  He was wheelchair bound during this time and attended physical therapy, which largely consisted of electrotherapy to the inner thigh muscles and exercises for the lower body. In March of 2023, the client broke the second metatarsal and second phalange in his right foot after he was tackled during a soccer game. He saw a doctor, but there was no intervention for the injury. 

Additional client history worth noting, though not particularly pertinent to this study, is that the client has high blood pressure, which he controls with use of Lisinopril.

Assessment

The day of the initial session (Fig 1.), the client complained of an aching pain in his low back, around his hips, and his right calf and ankle. The client stated that he sprained his right ankle while driving and that his ankle had been aching for a period of 2 days prior to the initial treatment. At the time of the initial session, the client’s self-reported current, worst, and best pain levels were five, eight, and four out of ten, respectively, using the NRS-11.

Upon observing the client’s posture before the initial treatment, the practitioner noticed that the client’s left knee and hip were both elevated and both hips were rotated laterally. The practitioner also palpated the client’s lower extremities during the session, finding that he had hypertonicity bilaterally in the lateral gastrocnemius head and soleus, felt more intensely on the right calf. He had hypertonicity bilaterally in the piriformis, vastus lateralis, semitendinosus, semimembranosus, and biceps femoris. The iliotibial band also felt stiff and/or tight. The practitioner felt many adhesions along the quadriceps attachment sites both above and below the knee. The right ankle was visibly inflamed and warm to the touch so the practitioner avoided working on the site of injury or anything distal to it. 

Using effleurage, petrissage, and knuckle kneading, the practitioner was able to decrease hypertonicity in the gastrocnemius, soleus, quadriceps, hamstrings, and piriformis bilaterally. The practitioner applied the same techniques along the iliotibial band to increase tissue flexibility. Friction was able to soften the adhesions at the quadriceps attachments above and below the knee. Lastly, the practitioner used upper body compressions which increased the overall relaxation of the client. 

Before the second session (Fig 2.), the client’s hips were both rotated laterally. The practitioner palpated hypertonicity in the piriformis, gastrocnemius, and soleus, but noted that the hypertonicity had decreased somewhat since the last session. The adhesions in the quadriceps attachments had softened, but there were adhesions palpated in the ankle as well. The practitioner tested the range of motion of the ankles in the second session and found that the client had limited dorsiflexion bilaterally and limited eversion in the left ankle. 

Effleurage and petrissage were used to decrease hypertonicity in the gastrocnemius and soleus bilaterally and increase tissue flexibility in the iliotibial band bilaterally. Petrissage using knuckles helped to decrease hypertonicity in the piriformis as well. The practitioner used friction to soften adhesions at the quadriceps attachments and ankles and upper body compressions to increase the relaxation of the client. The techniques used are all strokes of Swedish massage. This technique was chosen because it is the foundation for most massage therapy in the western world (Benson, 2019). There have been numerous studies on massage therapy as pain management, but few studying Swedish massage specifically.

Treatment Plan:

The treatment consisted of two 30 minute Swedish massages focusing on the lower body over the course of three days. The practitioner suggested to the client increasing his daily water intake to half of his body weight in ounces and to wrap or brace his right ankle.

Treatment Session:

Each session was 30 minutes long and focused on the lower extremities. There was one day of no intervention between the two treatment sessions.

Figure 1

Fig 1. SOAP Notes from the initial day of treatment. 

Figure 2

Fig 2.  SOAP notes from the final day of treatment.

Results:

Upon completion of the treatment plan, the practitioner observed that only the left hip was laterally rotated and the right knee and hip were now elevated. The practitioner also noted decreased hypertonicity in the gastrocnemius, soleus, quadriceps, hamstrings, and piriformis. The practitioner reported tissue of the iliotibial band having been loosened, as well as the adhesions in the knee and ankle softened during friction. Lastly, the practitioner stated that the client’s breathing became more slow and relaxed during compressions to the upper body.  

After the initial treatment, the client stated that he felt “pretty nice” and that his overall pain was better. He stated that his hips and low back hurt slightly worse than before the session, but claimed that that was normal for him after lying supine. Using the NRS-11, he rated his low back pain a three out of ten, hip pain a two out of ten, low leg pain a one out of ten, ankle pain a two out of ten, and overall pain a two out of ten.

 After the second session, the client reported feeling no hip pain and stated he felt very relaxed. He said the techniques applied to the knee “felt good.” He reported his low back pain a one out of ten, hip pain a one out of ten, low leg pain a one out of ten, ankle pain a two out of ten, and overall pain being a one out of ten, again in accordance with the NRS-11.

After completing each treatment session, the client reported improved pain levels, with the exception of his hip pain after the first session. He self-reported feeling relaxed and the practitioner effectively decreased hypertonicity and softened adhesions at the end of each session through palpations. The posture of the client changed after the second session. Instead of both hips being laterally rotated, only the left one was. The left hip and knee was no longer elevated and, instead, the right hip and knee were

These results indicate that the objective was met; Swedish massage is effective at managing and reducing pain levels in this client, as the client reported feeling decreased pain after each session.

Conclusion:

After two 30 minute Swedish massage sessions, the practitioner observations of decreased hypertonicity and softened adhesions in the lower extremities, along with the client reporting, mostly, decreased levels of pain after each session, the evidence of this study suggested that Swedish massage was an effective method for managing and reducing pain in a client with numerous lower extremity injuries. However, there were limitations to this study provided that: only one client was evaluated, the only quantitative aspects of this study were self-reported by the client, and that a total of only 2 sessions were completed over a short amount of time. The claim that Swedish massage is an effective tool for reducing and managing pain would both be better supported, as well as more generalizable, if more clients were evaluated and if more observations were quantitative.

References:

Benson, E. (2019, October 17). Swedish massage – The Complete Guide. Massage Therapy School serving North Idaho and Spokane. https://www.aicm.edu/blog/2018/2/25/swedish-massage-expec

Hartrick, C. T., Kovan, J. P., & Shapiro, S. (2003). The Numeric Rating Scale for Clinical Pain Measurement: A Ratio Measure? Pain Practice, 3(4), 310–316. https://doi.org/10.1111/j.1530-7085.2003.03034.x

Miake-Lye, I. M., Mak, S., Lee, J., Luger, T., Taylor, S. L., Shanman, R., Beroes-Severin, J. M., & Shekelle, P. G. (2019). Massage for Pain: An Evidence Map. Journal of alternative and complementary medicine (New York, N.Y.), 25(5), 475–502. https://doi.org/10.1089/acm.2018.0282 

“Swedish Massage .” Gale Encyclopedia of Alternative Medicine. (2019) Retrieved December 11, 2023 from Encyclopedia.com: https://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/swedish-massage