Expert Witness Insight: Common Reasons Why a Massage Client Injury Occurs
May 23, 2025
Most therapists sincerely want to help their clients feel better, whether the treatment is about relaxation, a specific injury, or pain. Unfortunately, in my work as an expert witness, I have seen both cases of well-meaning therapists who have seriously injured their clients and poorly trained therapists with big egos who have injured their clients.
In one case, a therapist intended to stretch a client’s shoulder yet pulled on the client’s arm with such force that the client needed two surgeries over the course of one year to fix the damage. In another case, a therapist’s aggressive approach to working on an aching forearm left that client needing six months to recover from complete loss of strength due to nerve damage. I also know of several cases where clients left the treatment room with severe back pain or broken ribs as a result of overly vigorous massages.
In addition to the horrific experience, pain, disability, and expenses that occurred for the clients, these cases also resulted in lawsuits, damage to the therapists’ reputations, and loss of professional licensure to practice. In some cases, careers were prematurely ended. What might be to blame? A lack of knowledge? An inflated ego? Poor judgment? Low-quality education? Inadequate skill? Likely a combination of all of those. Here are a few common reasons why an injury occurs during a massage.
Injuries Are More Likely When a Massage Therapist Doesn’t Take a History
Because injuries are more likely when a massage therapist doesn’t take a history, it’s always wise to take a client’s history before working on any client. It may be brief if it’s a relaxation massage, but it’s important to understand what you have to avoid. It’s best if the therapist asks each question face-to-face, but if they are under severe time constraints, having a questionnaire available for clients to fill out in advance saves time. Then, if anything needs clarification, the therapist can ask the necessary follow-up questions.
A more thorough history is required if the client is there because they are in pain. Most massage therapists do not specialize in pain and injury assessment and treatment, but every therapist should at least ask these questions:
Do you currently have a pain or injury problem in your body?
Finding out if a client has any present pain or injury lets the therapist know which areas to address with gentle pressure and caution or to avoid.
Where have you had pain or injuries in your body in the past?
Areas of previous injury are usually vulnerable and warrant extra care. If a client has had on-and-off back or neck pain, these areas may need special attention. For example, if a client has had a history of lower back pain while bending backward or standing, lying face down on the treatment table for any length of time may induce pain. This position arches the lower back and puts extreme pressure on the part of the lower back that likely has a minor injury. Beginner therapists often report that after clients lie face down on the table, they have difficulty getting up without pain. This is because massaging the lower back pushes the lower spine into an arched position, irritating whatever is damaged in the lower back.
Is there any part of your body that you don’t want to receive work on?
For many reasons, a client may not want the therapist to work on particular parts of their body. It may be as simple as wanting more focus on specific areas, or they may be self-conscious about their body or even associate emotional trauma with specific areas. Of course, the therapist never works on the private areas of the body.
Have you seen a physician about this problem? If so, what was the diagnosis?
Some serious conditions can cause back, neck, or headache pain that needs immediate medical attention. For example, severe headache pain could be the side effect of either a disc injury in the neck or a cerebral hemorrhage in the brain. Pain in the shoulder when raising the arm can indicate an injury to the shoulder or cancer of the lung. Pain in both heels could be plantar fasciitis, but also be a sign of gonorrhea, a venereal disease. If a client has not seen a physician about a pain problem in their body, it is always wise to encourage the client to see their doctor.
Do you have any other medical conditions I should be aware of?
It is always important to know what other issues or conditions a client may be experiencing aside from the specific reason for their visit. While a concurrent medical condition may not be the focus of a therapist’s treatment, it can’t be ignored. A colleague of mine was treating a woman who was undergoing chemotherapy for cancer and understood that, during cancer treatment, the therapist must work with very light pressure. A therapist without that understanding and training in oncology massage should not be treating anyone in cancer treatment. As another example, one of my recent clients came to me for knee pain but also had a history of blood clots and phlebitis, which put him at risk for conditions like Deep Vein Thrombosis or, worse, a pulmonary embolism. So, I focused on his knee and used only light pressure when working his legs. A therapist without this type of knowledge puts their client at risk. This question is extremely important to ask clients.
Are you taking any medications regularly?
If the client says yes, the therapist needs to know which medication because certain medications make the body more unstable, weak, or easily bruised. Well-trained therapists are aware of the common side effects associated with medications, including, but not limited to, aspirin, coumadin, ibuprofen, or Plavix. Certain medications, such as Celebrex, Oxycontin, Dilantin, Disulfiram, or Cisplatin, interfere with sensation or pain perception.
When clients take these medications regularly, injury or pain sensations are diminished, and so are their perception and sensitivity to pressure. Even if the therapist sees this person only once, they must work very gently.
Without taking a history, the therapist would be unaware of these things.
Injuries Are More Likely When a Massage Therapist Works with Too Much Force
Each person requires a slightly different amount of pressure in a massage. The more relaxed the person is, the more pressure can be used that feels good and is therapeutic. It should not be painful during a relaxation or deep tissue session. Some types of bodywork, like Rolfing or Structural Integration, are painful, but this type of work is not massage.
Clients may be injured during a massage because the therapist uses too much force. There have been multiple lawsuits for broken ribs from a massage done with too much force. Most therapists learn to use the right amount of pressure for each person, but a less-skilled therapist often uses an inappropriate amount of force.
Signals of Too Much Force
If the muscle suddenly tightens up as the therapist is working, this is a signal that too much force is being used. If the person winces and their body jumps slightly, this is a stronger signal that too much is being used. A skilled therapist will recognize this, lighten their pressure, and be mindful while working on this body part. A not-very-skilled or sensitive therapist will ignore the signal and plow ahead. And, of course, some clients will speak up and say, “That hurts!”
Just Ask
The easiest way to determine the right amount of pressure for each client is to ask—and to ask multiple times. Most clients will tell you if you ask. Skilled therapists ask the question often, especially with new clients. Some clients will not tell you because they are embarrassed to say it or think they should tough it out. They have the misconception that they will get a greater benefit if it hurts. With this type of client, skilled therapists watch their face for grimacing, or their muscles for tightening, as I described above.
Injuries Are More Likely When a Massage Therapist is Incompetent at Stretching
Stretching can be very beneficial or dangerous, depending on who does it and how it’s done. Stretching another person is a responsibility; it takes training, experience, and skill. In educated hands, stretching is gentle, repeated, and gradual. It requires the ability to sense through physical feedback in the practitioner’s hands when it’s enough. The word stretching implies “going farther,” stretching the limit. But if you go too far or too fast, you can injure someone.
For stretching to be safe, it takes a warm-up phase that gets the muscles ready to stretch. Muscles stretch farther and easier when they are warmed up. Stretching is also not a one-and-done event; it has to be repeated many times in each stretching session and done regularly over many months. The ultimate goal of stretching is to become more flexible. For that goal to be met, the resting length of the muscle fibers must change their position. Doing a forceful, unskillful stretch as part of a massage without a warm-up has injured shoulders, necks, and backs.
Competent, well-trained massage therapists don’t injure their clients. They take the time to take a history, use appropriate pressure, check in with clients regularly, and use techniques they are qualified to use. Client injuries happen when careless, distracted, poorly trained therapists don’t know how to match the treatment to their client’s needs.
If you’re a lawyer who is currently involved in a massage injury case and needs an expert witness with a massage or spa background, schedule a conversation with Dr. Benjamin.
Ben E. Benjamin holds a Ph.D. in Sports Medicine and has been an expert witness in cases of sexual assault in a massage/spa setting since 2004, advising lawyers, testifying in depositions and trials, and writing reports. His expertise extends beyond massage therapy and ethical behavior. He also advises spas, both large and small, on the creation of comprehensive sexual assault prevention strategies that ensure safe and ethical practices in the industry.