How Massage Therapists Can Help Athletes with Pain & Injuries
Athletes will experience pain. That’s not a possibility, it’s a guarantee.
The role of a manual therapist is not just to “fix” pain, but to help the athlete understand it, navigate it, and ultimately adapt in a way that allows them to keep training and performing. To do that effectively, we need a structured approach.
Step 1: Understand the Pain or Injury
Before you touch anything, you need as much information as possible. Here are the key questions to ask:
Was the onset traumatic or insidious?
Traumatic onset suggests a more acute event. Here, the priority is determining how significant the threat or damage is. If it’s severe, this is outside your scope and should be referred out.
Insidious onset is more often the result of accumulated microtrauma or degenerative processes. These cases require a broader lens.
How intense is the pain?
Pain intensity helps determine current irritability. If the tissue is highly aggravated, it needs time to calm down before loading. If it’s not highly reactive, you can begin introducing low-level stress and observe how it responds, often in real time, using techniques like MET or PNF.
Does it improve with a warm-up?
This is a useful differentiator. If it improves with movement, you’re likely dealing with a capacity issue rather than acute tissue damage. If it worsens or remains highly sensitive, you may need to treat it more conservatively, almost like a “virtual surgery.”
How specific is the pain?
Two key questions:
Load-specific: Does it only hurt under heavier loads, or even with lighter ones?
Movement-specific: If you modify stance, grip, or position, does the pain change?
If small changes reduce pain, that’s a good sign. It means you can modify the activity while addressing underlying deficits (we call these replacement behaviors). Asking your athlete to make these modifications for a short term is a reasonable step in the rehab process.
Have there been recent changes to their lifestyle or training?
Increased training volume or intensity, changes in programming, life stressors (breakups, job loss, etc.). These matter. Pain doesn’t exist in a vacuum and often is a result of a change that happened too quickly for the body to accommodate.
Step 2: Look at the Other 23 Hours of the Day
You’re not just treating what happens on the table, you’re influencing everything outside of it. The first stop is sleep. Recovery happens during sleep. Training is simply the stimulus. If sleep is poor, then there’s no recovery, if there’s no recovery, there’s no adaptation, and likely only breakdown. The second is stress. Chronic stress raises the overall load on the system. If someone’s “bucket” is already full, even small physical stressors can become problematic. Often, the weakest link is what starts to hurt. Third is nutrition. We need to be asking about protein intake because that affects tissue repair. We know that Alcohol impairs recovery and depletes nutrients from the liver. A highly processed diet can increase systemic inflammation, and Low energy availability (caloric restriction) limits the body’s ability to adapt. New tissue is not free; the system needs resources.
Step 3: Assessment
If we factor out lifestyle contributions, now we can start identifying what’s actually contributing to the issue.
What movements are painful?
Ask clients to rate their pain from specific movements on a scale of 1-10. Avoid loading any movements above a 3/10 pain threshold. Sometimes it’s helpful to think in terms of starting over with these patterns if needed. Have them pretend they just had surgery, and they're literally starting over. For example, in a client with a shoulder injury, I may ask them to bench press only the bar for 1 week, and then progress ONLY by 10 lbs each week. Some athletes may think this is crazy, but it hits the reset button and gives an optimal timeline to recover and rebuild. Athletes often want to rush the process and expect they’ll be able to bounce back quickly. It has been my experience that the more the athlete tries to rush the comeback, the longer the comeback actually takes because they continue to “pick the scab”, instead of allowing it to fully heal and rebuild properly.
Where are the functional limitations?
Hopefully, you’re running a movement screen. We need to look for mobility restrictions and motor control deficits. If one joint isn’t doing its job, adjacent joints will compensate. The body operates as a system, not isolated parts, but in order to know if the body is operating optimally, we need to examine each isolated part to make sure they’re capable of doing their job. This is why in the TheraPro Method Assessment, we use both MacroMovement assessments and Limitation Locators.
Step 4: Hands-On Work
Treatment is not just reducing symptoms; it’s about changing the environment the nervous system is operating in. That’s what we’re really trying to do with our hands. But the first step is to reduce pain. Using compression, Effleurage, and general manual therapy can reduce pain through several mechanisms:
The first is simple Pain Gating. Small fibers (A-delta and C-fibers) carry pain signals, Large fibers (A-Beta) carry touch and pressure. Stimulating touch receptors can inhibit pain signals at the spinal cord level.
We also have Descending Modulation, where massage therapy can stimulate the release of Endorphins, Serotonin, and Oxytocin, and these alter how pain is perceived at the brain level.
Further, parasympathetic activation, which reduces muscle guarding, decreases stress hormones, and induces relaxation, can also aid in reducing pain.
We can’t exclude circulatory and lymphatic impact, which may also play a role in pain signalling. Massage can improve fluid movement, which may clear inflammatory metabolites, deliver nutrients and oxygen, and reduce chemical irritation of nociceptors.
Don’t forget: If you take something away, you must give something back!
With hands-on work, we’re doing a lot to reduce tension and muscle guarding, but it’s important to remember that this tension is protective and functional! If we take away protection, we must offer protection in another way, and this is where active techniques come in handy. We want to stimulate underactive or inhibited areas to encourage stability.
Techniques like PNF and manual resistance allow us to introduce a controlled stimulus that encourages the appropriate muscles to engage and contribute to the movement. By doing this, we’re not just taking away tension; we’re helping the nervous system reorganize how stability and control are achieved. Think of these as activation strategies that give the system a better option, rather than simply removing the old one and hoping it figures it out on its own.
Final Thoughts
There’s so much more we can do as therapists, and this article could become an entire book if I’m being honest. But the truth is that long-term outcomes are determined less by what happens on the table and more by what the client does afterward. One of the first priorities is to stop repeatedly aggravating the issue. If a specific movement or load is provoking pain, we need to modify it. That might mean changing grip, stance, implement, or range of motion, but the goal is the same: keep the athlete training in a way that stays within a tolerable threshold while the irritated tissue calms down. There is almost always a way to maintain some version of the movement without continuing to “pick the scab.”
From there, we need to manage load and exposure. If the pain is load-dependent, we reduce the load to a level that is relatively pain-free and then progressively build it back up. If it’s range-of-motion dependent, we temporarily remove the provocative range and gradually reintroduce it over time. Isometrics are often a useful starting point because they allow us to precisely control both intensity and position while also providing a meaningful stimulus for tissue adaptation. Throughout this process, pain serves as feedback: if symptoms worsen, we’ve likely exceeded capacity; if they improve, we continue progressing in that direction.
Finally, we need to address the underlying limitations that contributed to the issue in the first place. If the problem is mobility, we need to restore a usable range of motion. If it’s motor control, we need to improve strength, coordination, and stability within that range. Manual therapy can create an opportunity for change, but without reinforcing that change through movement and loading, the system will default back to its previous state. The goal is not just to reduce pain, but to build a system that can tolerate the demands being placed on it.
All these topics and more were covered in episodes 40 and 41 of the TheraPro Show. If you’re not a listener, you might want to become one!