Massage therapists often see the same clients as doctors, with the exact same complaints. Because of the limited scope of their training, it is much more difficult for Registered Massage Therapists to understand the underlying pathology — they simply lack the necessary conceptual tools. Nevertheless, it is very useful to at least determine the general direction and identify the main mechanism of pain for each individual client.
Below is a simple scheme that helps minimise mistakes, work consciously, and clearly explain to the client what to do next.
Step 1. Localisation and Character of Pain
Ask the client to point with a finger exactly where it hurts. It is important that they point, not describe it in words. Do not explain anything beforehand so as not to lead the client in the wrong direction. Simply say: “Show me with your finger where it hurts.” Pay attention to how they do it.
Local pain
The client clearly points to a small, specific spot. Recall anatomy and consider which structures of appropriate size could be there. Usually, these are a facet joint, a vertebra, or a local muscle.
Wide area
The client traces a relatively large area with their finger. In most cases this indicates a muscle.
Band-like area
This zone often extends into the arm or leg. In such cases, dermatome charts are very helpful. It is good to have one in the office, study it in your free time, and practise a little. Many charts also show peripheral innervation zones.
The usefulness of such charts is hard to overestimate. If you also add a chart of the main muscles, you get an excellent diagnostic tool. You can quickly match the painful area with specific muscles, innervation zones, or dermatomes.
Character of pain
Sharp, electric, shooting, or band-like pain is more often related to nerves. Dull, aching pain is more often related to muscles or joints. Do not confuse sharpness with intensity. Very intense pain is always a warning sign — be careful, and be ready to stop the massage if needed.
Step 2. History of the Problem
Ask the client what happened. Identify any red flags, possible causes, and how long the problem has been present. This information won’t help establish the cause, but it clarifies the potential mechanism and helps identify red flags.
Presence of trauma
If the client says the pain started after an injury, clarify exactly what happened and when. If the trauma was serious, recent, and the client has not seen a doctor — this is a red flag. Be very cautious in such cases. For a detailed overview of red flags in spinal pain, refer to established clinical guidelines.
Episodes of unusual physical activity
Clients often recall some unaccustomed physical effort after which the pain began. A detailed conversation can reveal the likely cause of the back pain.
Prolonged sitting
Sometimes the client mentions nothing special except that they sit a lot. This can also cause back pain.
Step 3. Pain Behaviour with Movement
Since we are dealing with the spine, immediately check the main movements: forward bending, backward bending (extension), and rotation. Do this carefully — never push the client into severe pain.
Possible patterns:
Pain increases with backward bending
This is often related to the small facet joints of the spine.
Pain increases with forward bending
This is often related to the intervertebral discs or muscles.
Pain with rotation
This happens less often. It may be related to the joints or muscles. Rotation usually increases pain when combined with backward bending on the affected side.
Pain especially strong when returning from forward bending
When the client bends forward and then straightens up, and the pain sharply increases at that moment — this often indicates a disc-related problem.
These movement patterns are inspired by the McKenzie Method of Mechanical Diagnosis and Therapy.
In addition to pain, assess the range of motion and note any restrictions.
Step 4. Quick Neurological Check
Upper back and neck
- Ask: “Do you have any symptoms below the shoulders?” — pain, numbness, or tingling in the arms or a band-like sensation in the chest. If yes — suspicion of nerve involvement. Compare with the information from Step 1 and the dermatome charts.
- Palpate the area where the symptoms spread. If the pain there matches what the client originally described — it is more likely soft tissue. If not — nerve involvement is possible.
Lower back
- Does the pain radiate into the leg below the knee? If yes — higher chance of nerve involvement. If no — nerve involvement is unlikely.
- Is there numbness or tingling in the leg? No — probably not a nerve. Yes — the nerve is likely involved.
- Check for weakness in the feet. Ask the client to walk on toes and on heels. Weakness more often points to nerve involvement.
Step 5. Palpation
Start palpating the spine near the area the client pointed to. You can begin slightly above or below. First press directly on the spinous processes (front to back). Then press sideways (left to right and right to left). The goal is to find the most painful segment.
Next, palpate the muscles on both sides of the spine (about two fingers’ width from the centre). Look for the most tender spots.
If the painful area is not on the spine itself, palpate it and compare with the same area on the opposite side.
Palpation findings
Protective muscle spasm around the painful area is present in virtually all cases. Beyond that:
- Diffuse tenderness within a specific muscle, reproducing the complaint → muscle
- Pinpoint deep tenderness at segment level → facet joint
- Nothing specific beyond spasm → disc / nerve root
With back pain there is almost always some protective muscle tension. This fact by itself does not tell us the exact cause, but it does show the amount of work needed for the massage.
Conclusion
After completing these steps, you will usually have a clearer picture of the main cause of the client’s back pain.
Compare:
- where it hurts (Step 1),
- the history (Step 2),
- how pain behaves with movement (Step 3),
- signs of nerve involvement (Step 4),
- findings from palpation (Step 5).
This helps determine which structures are mainly involved: muscles, discs, joints, or nerves. You can also assess the severity of the problem and provide appropriate recommendations.
If the process is acute and there are signs that discs or nerves may be involved — it is better to recommend seeing a doctor.
The most important thing: this information helps you understand what you can realistically do and how effective your work is likely to be. If the problem is mainly muscular — you have a good chance of really helping the client. If discs or nerves are heavily involved — the possibilities of massage become much more limited.
Review your findings as a whole. Assess which tissue is most likely involved — this is a judgment call, not a mechanical count. You may revisit and recheck specific findings along the way. In most cases a reasonably clear conclusion will emerge.
Once this algorithm is complete, you may apply your full clinical knowledge to further refine the diagnosis: expand the history, perform orthopedic tests, and so on.