A deeper look at the conditions that hide behind common musculoskeletal symptoms — and how to recognise them
In Part One, we explored the framework of red flags, contraindications, and precautions, and considered how evidence-informed thinking has moved the profession away from blanket avoidance toward nuanced clinical reasoning. In Part Two, we look more closely at specific conditions, what they are, how they can masquerade as straightforward musculoskeletal presentations, and how they affect hands-on practice.
The conditions covered here are not exotic or rare. They sit in the waiting rooms of GP surgeries across the UK every day, and a meaningful proportion of your clients may be living with one of them, diagnosed or not. The more you understand about these conditions, the safer your practice becomes, and the more effectively you can support your clients.
1. Rheumatoid Arthritis (RA)
What It Is
Rheumatoid arthritis is a chronic, systemic autoimmune condition characterised by persistent synovial joint inflammation. Unlike osteoarthritis, which is primarily a degenerative condition, RA involves the immune system attacking the synovial lining of joints, leading to pain, swelling, stiffness, and, if poorly controlled, progressive joint damage and disability.
RA affects multiple systems beyond the joints, including the cardiovascular, respiratory, and haematological systems. It is approximately three times more common in women than men, and while it can occur at any age, onset most commonly occurs between 40 and 60 years of age. I am not certain of the precise current UK prevalence figure, and recommend verifying this through Versus Arthritis or NICE publications.
How It Can Hide
The early stages of RA may present to you as what appears to be straightforward joint stiffness, often symmetrical, affecting the small joints of the hands, wrists, and feet. The classic morning stiffness lasting more than 45 minutes is a distinguishing feature, though clients may not volunteer this without direct questioning.
Clients with undiagnosed RA may come to you with generalised upper body stiffness, neck tension, and bilateral hand or wrist pain, symptoms that could easily be attributed to desk-based work or postural habits. The clues that should raise your index of suspicion are symmetry, involvement of multiple small joints, constitutional features (fatigue, low-grade fever, feeling generally unwell), and stiffness that is markedly worse in the morning and improves with movement.
| 🩺 Clinical Scenario: Possible Undiagnosed RA A 47-year-old female client books for a full body massage, reporting ‘aching all over’ and particular stiffness in her wrists and fingers. She mentions she’s been tired lately and assumes it’s work stress. She says her hands feel ‘like claws’ when she wakes up but loosen up after an hour or so. Clinical flags: bilateral small joint involvement, prolonged morning stiffness, systemic fatigue. This pattern warrants GP referral for further investigation, including inflammatory markers (CRP, ESR) and rheumatoid factor / anti-CCP antibodies. Action: You can proceed with general relaxation massage avoiding inflamed joints, but should recommend GP review and document your concern clearly. |
How RA Affects Hands-On Practice
For diagnosed clients, your practice must adapt depending on disease activity. During a flare, characterised by hot, swollen, tender joints, avoid direct work over inflamed areas. Massage to surrounding musculature can still be beneficial, and gentle, supportive touch is generally appropriate and valued by clients.
Outside of flares, massage therapy can play a meaningful supportive role in managing muscle tension, improving local circulation, and supporting wellbeing. Be particularly cautious in clients with long-standing RA around the cervical spine. Atlantoaxial instability, subluxation of the joint between C1 and C2 — is a well-recognised complication of RA due to ligamentous laxity, and aggressive cervical manipulation carries real risk. Gentle soft tissue work around the neck is generally safe; high-velocity cervical techniques are not within the scope of massage therapy and should never be performed regardless.
Always check medication: clients on disease-modifying antirheumatic drugs (DMARDs) such as methotrexate or on biologics may have increased infection risk and skin fragility. Clients on long-term corticosteroids may have osteoporosis and bruise easily.
2. Osteoporotic Compression Fractures
What It Is
Osteoporosis is a systemic condition characterised by reduced bone mineral density and deterioration of bone microarchitecture, leading to increased fracture risk. Vertebral compression fractures are the most common osteoporotic fracture and can occur with minimal trauma, sometimes with no identified incident at all. They are significantly underdiagnosed because many are asymptomatic or present with symptoms that appear indistinguishable from non-specific back pain.
How It Can Hide
A client with a vertebral compression fracture may present to you with what appears to be acute or subacute thoracic or lumbar back pain. They may attribute it to a recent activity, lifting, gardening, a minor fall, or to no event at all. The pain is often described as a sudden, sharp onset that has now become a persistent, dull ache. It may be worse with movement and partially relieved by rest.
Risk factors that should increase your clinical suspicion include: female sex, post-menopausal status, age over 65 in women or over 70 in men, long-term corticosteroid use, history of previous fragility fracture, low body weight, smoking, and significant alcohol intake. In men, hypogonadism is a relevant risk factor. Clients may be unaware of their osteoporosis status, many people are only diagnosed following their first fracture.
Red flag features in this context include: acute onset thoracic or upper lumbar pain in a high-risk individual, pain that is severe and unremitting, pain associated with trauma (however minor) in an older adult, or a recent history of height loss.
| 🩺 Clinical Scenario: Possible Vertebral Compression Fracture A 71-year-old female client with a known history of osteoporosis presents with acute onset mid-thoracic pain that started three days ago after she ‘twisted slightly’ to reach something on a shelf. She rates the pain 7/10 at rest and says it is worse on movement. She has not seen her GP. Clinical decision: Do not massage the thoracic region. This presentation — acute onset thoracic pain following minimal activity in a client with known osteoporosis — is consistent with a compression fracture and requires medical assessment before any hands-on treatment. Recommend she see her GP or attend urgent care for assessment including imaging. You may proceed with very gentle work to the lower limbs if appropriate and if the client is comfortable, but document your decision and the advice given. |
How Osteoporosis Affects Hands-On Practice
For clients with known osteoporosis without acute fracture, massage can be safe and beneficial with appropriate adaptation. The key principles are: use lighter pressure throughout, avoid percussive techniques over the spine and thoracic cage, use careful positioning with adequate support, and avoid any technique that applies compressive or rotational force to the vertebral column.
Adapt your table height and use bolsters generously. Consider prone positioning carefully, some clients with significant kyphosis or respiratory compromise may not tolerate prolonged prone lying. Side-lying or semi-reclined positioning may be more appropriate.
3. Inflammatory Bowel Disease and Referred Pain Patterns
Conditions including Crohn’s disease and ulcerative colitis can produce abdominal and low back pain patterns that bring clients to manual therapists. Clients may not connect their bowel condition to their musculoskeletal symptoms, and the overlap between referred visceral pain and lower back pain can be clinically challenging.
Signs that should prompt consideration of a visceral source include: pain that is not clearly posture-dependent, pain that is unaffected by movement, pain associated with systemic features (altered bowel habit, rectal bleeding, abdominal cramping, unexplained weight loss), or pain that is consistently worse after eating. In these presentations, refer to the GP for review before continuing with treatment of the lumbar region.
5. Ankylosing Spondylitis and Axial Spondyloarthropathy
Axial spondyloarthropathy (axSpA) , which includes ankylosing spondylitis, is an inflammatory arthritis affecting the spine and sacroiliac joints, with onset typically in young adults, often before the age of 40. It is significantly underdiagnosed, with an average delay from symptom onset to diagnosis that has historically been measured in years. Many clients with undiagnosed axSpA present to massage therapists with what appears to be chronic low back pain.
The distinguishing features are important to recognise: inflammatory back pain (IBP) in axSpA tends to be insidious in onset, present for more than three months, worse with inactivity and significantly improved with exercise or movement, and associated with significant morning stiffness. The pattern is the inverse of typical degenerative back pain, which is usually worse with activity and relieved by rest.
Additional features include alternating buttock pain (reflecting sacroiliitis), peripheral joint involvement, enthesitis (tendon attachment point pain, particularly at the Achilles), uveitis, and psoriasis. If a young adult client presents with chronic low back pain fitting this pattern, a GP referral for inflammatory marker testing and, if indicated, MRI of the sacroiliac joints is appropriate.
6. Cardiovascular Conditions and Thoracic Presentations
Pain originating in the cardiovascular system, including the heart, aorta, and coronary vessels, can refer to the thoracic spine, upper back, shoulders, and left arm in patterns that may bring a client to a massage therapist. Cardiac ischaemia classically presents with central chest pain radiating to the left arm and jaw, but atypical presentations are common, particularly in women, older adults, and people with diabetes.
Aortic aneurysm, which may be present without symptoms until rupture, can produce deep, boring thoracic or lumbar back pain. A client over 65 with a history of smoking, hypertension, or known cardiovascular disease presenting with unexplained central or lateral thoracic spine pain, particularly if it is pulsatile or unrelenting, requires same-day medical assessment.
If a client develops chest pain, breathlessness, or sweating during a session, stop treatment immediately and follow your first-aid training and workplace emergency protocol.
Communicating with Healthcare Providers: Writing a Referral Note
Effective referral requires more than telling a client to see their GP. In some cases, particularly where you have specific clinical observations to share, a brief written referral note adds significant value and supports continuity of care. Most UK massage therapists are not trained to write formal clinical referral letters, but a clear, professional note is well within scope and is good practice.
A concise referral note should include:
- Your name, qualifications, and professional registration number
- The date of contact with the client
- A brief description of the client’s presenting complaint and relevant history as disclosed during assessment
- The specific signs or symptoms that prompted your concern
- The clinical action you took (e.g., deferred treatment, advised GP review)
- Your contact details if the receiving clinician wishes to follow up
Example note: ‘I assessed this client in my capacity as a qualified massage therapist on [date]. She presented with a two-month history of bilateral proximal shoulder and hip girdle stiffness with significant morning stiffness and fatigue. Given her age and symptom pattern, I recommended she seek GP review to exclude inflammatory pathology including polymyalgia rheumatica. I deferred treatment pending medical assessment. Please do not hesitate to contact me if further information would be helpful.’ [Name], [Qualification], CNHC Registration No. XXXXXXXX
Give the note to the client to take with them, or, with explicit consent, send it directly to the practice. Keep a copy in your own records.
| Key Takeaways from Part Two Rheumatoid arthritis, PMR, and compression fractures can all hide behind common musculoskeletal presentations — know the distinguishing features. Osteoporotic fracture can occur with minimal or no trauma in high-risk individuals — adapt pressure and avoid compression over the spine. Axial spondyloarthropathy is significantly underdiagnosed in young adults with chronic inflammatory back pain. Recognise the pattern. Visceral conditions including cardiac, aortic, and bowel pathology can mimic musculoskeletal presentations. A brief, professional written referral note supports the client and the receiving clinician — make it part of your practice. The most skilled clinical decision you can make is sometimes the one that keeps your hands still. |
Part Two of Two. This article is intended as a professional development resource for qualified massage therapists registered with, or working toward registration with, a UK professional body such as the CNHC, MTI, or GCMT. Clinical information is based on the author’s understanding of established evidence and clinical guidelines and is provided for educational purposes only. It does not constitute medical advice and does not replace your professional body’s current guidance, your employer’s clinical governance policies, or your obligations under applicable UK legislation. Verify specific clinical guidance is current at the time of reading, as guidelines are subject to revision.
Appendix to this Blog
Before performing any massage, therapists should complete a consultation, check medical history, and identify whether treatment is safe, needs adapting, or should be avoided altogether.
Here’s a practical breakdown for Deep Tissue, Sports, Swedish, and Maternity massage.
General Categories
1. Red Flags (Stop & Refer)
These may indicate serious illness or medical emergency. Massage should not proceed until medically cleared.
Common red flags for all massage types:
* Chest pain or breathing difficulty
* Suspected blood clot / DVT
* Sudden swelling, redness, or heat in a limb
* Fever or infectious illness
* Unexplained severe pain
* Loss of sensation or paralysis
* Recent head injury/concussion symptoms
* Uncontrolled high blood pressure
* Cancer symptoms not medically assessed
* Severe osteoporosis with fracture risk
* Open wounds, burns, contagious skin conditions
* Severe allergic reactions
* Acute inflammation or infection
2. Contraindications
Absolute Contraindications (Massage should not be performed.)
Examples:
* Fever
* Contagious disease
* Acute thrombosis/DVT
* Severe infection
* Active bleeding
* Severe intoxication
* Unstable heart conditions
* Recent major surgery without medical approval
* Severe uncontrolled diabetes complications
* Acute trauma/fracture
* Severe skin infection
Local Contraindications (Massage may continue but avoid specific areas.)
Examples:
* Bruising
* Varicose veins
* Cuts/wounds
* Local inflammation
* Sunburn
* Recent scar tissue
* Skin rashes
* Recent injections
* Broken bones
* Hernias
1. Deep Tissue Massage
Precautions
Deep tissue uses stronger pressure, so extra caution is needed with:
* Elderly clients
* Clients on blood thinners
* Chronic pain conditions
* Fibromyalgia
* Diabetes with neuropathy
* Osteoporosis
* Recent injuries
* Hypermobility
* Pregnancy
* Low pain tolerance
Specific Contraindications
Avoid deep pressure over:
* Inflamed tissue
* Recent surgical sites
* Varicose veins
* Nerves
* Kidneys/anterior neck
* Acute injuries
* Bruised tissue
Therapist Watchouts
* Client holding breath
* Sharp/radiating pain
* Excessive bruising
* Dizziness or nausea
* Post-treatment soreness beyond 48 hours
2. Sports Massage
Precautions (Sports massage may be vigorous and condition-specific.)
Be careful with:
* Acute injuries (<48–72 hrs)
* Muscle tears
* Tendon ruptures
* Overtraining syndrome
* Dehydration
* Joint instability
* Stress fractures
* Concussion history
Specific Contraindications
Do not massage:
* Acute inflammation
* Fresh sprains/strains
* Fractures
* Severe DOMS with swelling
* Active infections
* Heat/swelling from injury
Therapist Watchouts
* Swelling after treatment
* Sharp pain during ROM testing
* Numbness/tingling
* Loss of strength
* Signs of compartment syndrome
3. Swedish Massage
Precautions
Usually gentler, but still assess for:
* Frail skin
* Elderly clients
* Low blood pressure
* Anxiety/panic disorders
* Pregnancy
* Sensitive skin
* Medication effects
Specific Contraindications
Avoid:
* Skin infections
* Severe sunburn
* Acute illness
* Severe edema
* Uncontrolled cardiovascular conditions
Therapist Watchouts
* Dizziness when standing
* Emotional release/distress
* Skin irritation from oils
* Fainting risk in hypotensive clients
4. Maternity Massage
Major Precautions
Requires specialist knowledge
Important considerations:
* Trimester stage
* Positioning (avoid prolonged supine lying after first trimester)
* Blood pressure changes
* Pregnancy complications
* Pressure sensitivity
* Risk of dizziness
Absolute Contraindications
Massage should be avoided unless medically cleared if the client has:
* Pre-eclampsia
* Severe swelling/high BP
* Vaginal bleeding
* Placental complications
* Risk of premature labour
* Severe abdominal pain
* Blood clot risk
* Fever/infection
* Reduced fetal movement
Areas Requiring Caution
* Deep pressure on legs (clot risk)
* Certain abdominal work
* Overheating
* Excessively strong pressure
Therapist Watchouts
* Dizziness
* Shortness of breath
* Cramping
* Headache
* Visual disturbances
* Sudden swelling
Good Practice for All Massage Therapists
Before Treatment
* Consultation & informed consent
* Medical history update
* Medication check
* Pain scale assessment
* Explain possible after-effects
During Treatment
* Check pressure regularly
* Watch body language
* Maintain draping/privacy
* Monitor breathing and comfort
Aftercare
* Hydration advice
* Avoid strenuous exercise if appropriate
* Explain normal soreness vs abnormal pain
* Advise medical referral if symptoms worsen
In the UK, these precautions are commonly aligned with guidance from professional bodies such as Federation of Holistic Therapists and Complementary and Natural Healthcare Council.