Friction Massage


Friction is a massage technique used to increase circulation and release areas that are tight; particularly around joints and where there are adhesions within the muscles or tendons[1][2].  Friction is defined as “an accurately delivered penetrating pressure applied through fingertips”[3] . Cyriax, who is seen as the founder of the friction therapy, believed that deep frictions are appropriate for the treatment of tendinopathy, muscle strains, ligament lesions and scar healing


The role of the therapist is to minimize the scarring that develops perpendicular to the actin and myosin filaments, to facilitate the proliferation of the fibroblasts in the scar and to develop a strong, mobile scar that won’t be a source of recidivate pain when returning to normal activities[4].

The goal of friction massage is to influence cell behavior in all soft tissues. Friction massage is supposed to induce[4][5]:

  • Traumatic hyperemia, which helps to evacuate pain triggering metabolites.
  • Movement of the affected structure which prevents or destroys adhesions and helps optimize the quality of scar tissue and mechanoreceptor stimulation.
  • Stimulation of mechanoreceptors, producing a quantity of afferent impulses that stimulate a temporary analgesia.
  • Fibroblastic proliferation, responsible for the repair en regeneration of collagen.
  • Realignment of collagen fibers, determined by the magnitude of applied pressure[6].


The 8 rules of deep friction massage are[4] :

  • Diagnostic movements and palpation must single out the tissue at fault and the exact location on that tissue.
  • The physical therapist’s fingers and patient’s skin must move simultaneously to avoid injury to the skin.
  • The massage must be given perpendicular to the tissue’s fiber to smooth the scar down.
  • The massage must be given with sufficient sweep to assure that the whole scar is treated.
  • The friction must be given deeply, administered within the patient’s pain tolerance. The pain will gradually diminish during the massage.
  • The patient must adopt a posture that will adequately expose the tendon.
  • If the lesion lies in the belly of the muscle, the muscle must be put on slack. This will aid in separation of the muscle fibers during the massage.
  • Tendons with a sheath must be put on stretch to assure maximum success of the massage.

The contraindications include skin diseases, inflammation due to bacterial action, traumatic enrheumatoid arthritis, calcification in soft tissue, bursitis and tunnel syndromes[4].

Key Research

However, there is no scientific evidence supporting such assumptions because massage is unlikely to increase muscle blood flow[7][8] and studies are lacking on the effects of massage on the realignment of fibers. Nevertheless the inflammatory response to damaged muscle fibers causing a transfer of fluid and cells to damaged tissue is an established fact[9]. The increased fluid produces swelling after injury. Neutrophils and macrophages migrate to the inflammatory sites and play a role in both the damage and repair processes[10].

Literature about the effects of friction massage in the treatment of tendinitis provides us several insides. In 1997 Davidson et al.[5] created a tendinitis in a rat’s achilles’tendon by injecting the enzyme collagenase. This injection caused a collagen fiber disruption and misalignment. Afterwards they applied longitudinally augmented soft tissue mobilization on the tendon which resulted in fibroblast activation, leading to collagen synthesis. Friction massage is said to stimulate the proliferation of fibroblasts and collagen fiber realignment with cross linkages[11].They also performed a gait analysis which exposed an improvement in the step length and frequency. A case report[12] demonstrated the potential benefit of a multimodal approach in patients with a shoulder impingement. This conclusion is supported by earlier articles[13][14][15][16][17][18] that suggest the multimodal approach is an appropriate method for the successful conservative management of shoulder problems. This approach consisted of following interventions: soft tissue therapy including friction therapy, ultrasound phonophoresis, manipulation and exercise. Longitudinal and transverse frictions were applied to the posterior tenomuscular junction of the infraspinatus muscle, the coracoacromial ligament and the insertion of the supraspinatus on the greater tubercle of the humerus. The transverse motion across the involved tissue and the resultant hyperaemia are said to be the main healing factors of friction massage. The hyperaemia is supposed to release histamine and bradykinins resulting in vasodilation and reduction of oedema[19]. The transverse action is said to prevent the formation of scar tissue while longitudinal friction effects the transportation of blood and lymph[20]. A successful management of a chronic bursitis by using a soft tissue friction massage was also mentioned by Hammer[19].

But not all articles were in favor of friction therapy; a research report[21] concluded that the manipulation of the wrist was found more effective than ultrasound, friction massage, muscle stretching and strengthening exercises for the management of lateral epicondylitis when there was a short-term follow-up. A reinforcement for this insight can be found in the trail of Brosseau et al.[22] where no benefit was found for patients with extensor carpi radialis tendinitis concerning the control of pain or improvement of grip strength by using deep transverse friction massage. Furthermore this trial showed no significant difference for patients with an iliotibial band friction syndrome in 3 types of pain relief and functional status, measured after 4 consecutive sessions of deep transverse friction massage combined with other physiotherapy modalities. The only clinically important relative percentage difference in pain (22%) was measured while running. An RCT[23] that aimed to compare the effectiveness of an exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy concluded that an exercise programme was more effective than ultrasound and transverse friction at the end of the treatment as well as at the follow-ups. As described by Cyriac[24] the transverse friction was applied for 10 minutes continuously to the patellar tendon.

We can conclude by saying that with the limited evidence, there is still a lot of research to do about friction massage. A lot of RCT’s are lacking a control group, are limited by the small sample size and are only investigating the short-term effects. Therefore it is very difficult to draw conclusions regarding the specific effects of frictions in the treatment of tendinitis and other conditions.


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