09/02/2026
Not everyone is sturdy enough for a “deep tissue” massage — not even seemingly healthy people — because many underdiagnosed pathologies, genetic quirks, and medication side effects can make muscle and fascia more fragile at any age.
[UPDATE: Obviously not all strong massage is harmful. No need to comment to that effect. 🙂 That's not the point I’m making. The point is that there is probably more POTENTIAL harm than most people suspect.]
The NON-RARE possibilities include: hypermobility, hypothyroidism, vitamin D and iron deficiencies, a bunch of inflammatory myopathies, and perimenopause or other low-gonadal-hormone states.
The DRUGS that can make us more “breakable” are the statins, oral corticosteroids, and fluoroquinolone antibiotics.
Most of these are minor, but not all, they are EXTREMELY common, and all of them can quietly lower tissue load tolerance, impair repair, and make muscles, connective tissue, and even tendons and ligaments behave less like tough rope and more like aging rubber bands — still stretchable, but slower to rebound, easier to irritate and damage. There are many more examples that are relevant to body pain in other ways, but literal FRAGILITY is the emphasis here: easier tearing.
But wait, there’s more!
There are also several RARE diseases that do this, but they are NOT rare when considered together. All kinds of rarer diseases collectively affect at least 4% of people worldwide — that’s 400 million people, well established as a bare minimum. Several of those cause soft tissue fragility: facioscapulohumeral muscular dystrophy (FSHD), mitochondrial disease, Loeys–Dietz syndrome, Marfan syndrome, eosinophilic fasciitis, and amyloidosis, sarcoidosis, and lupus.
People with these conditions often have body pain that motivates them to seek out help for it. A great many of them don’t know they’re vulnerable, and neither do most of the professionals they hire to, say, dig into their “knots.” But there are elevated risks for all of them if they get deep massage, acupuncture, dry needling, forceful fascial stretching, scraping, or other high-intensity manual therapies. These methods can easily overshoot unsuspected biological limits, provoking soreness, micro-injury, or flare-ups rather than recovery. And occasionally the consequences are even worse.
Even chronic pain itself is a kind of vulnerability: not from physical fragility, but from sensitization. Painful treatment can make a bad situation worse in a neurological way.
These conditions may also make people more vulnerable to postural and ergonomic stresses, but this is probably still a minor concern compared to the risks of intense massage.
This is why manual therapy intensity should be a clinical safety variable, not a badge of therapeutic virtue. Gentler, graded inputs make far more physiological sense in most cases.
That was the “abstract” for a whole new article that I have impulsively written and published in the last couple weeks, somehow finding time in the cracks for something that wasn't even on my project list. The topic has been on my mind for years and it suddenly seemed high time when I referenced it in a recent blog post (“Ideas for improving pain care”).
So there’s plenty more detail where that intro came from, if you’re interested! Ten times the words, references, and a full audio version. Link in the comments.
THE NEW ARTICLE:
“Sneaky Soft-Tissue Fragility: Many underdiagnosed health problems reduce the resilience of muscle and connective tissue, increasing the risks of “deep” massage”
~ Paul Ingraham, PainScience.com publisher
