When is Bruising Appropriate?

by Mitch Hauschildt, MA, ATC, CSCS

There has been a lot of different opinions in recent years on whether or not bruising is acceptable during manual therapy.  Many supporters of bruising with therapy (specifically Instrument Assisted Soft Tissue Mobilization) even refer to it as “therapeutic bruising”.  They have encouraged the practice of scraping people with tools to create a bruising effect in order to elicit some sort of a healing response.  Many patients have even begun to ask for bruising with their treatments because they believe that it is the only way that they will achieve healing.  We have also seen the round bruises that are usually a byproduct of cupping.

The major question becomes, is bruising a good thing?  It has become a major question that many of us have asked and to be honest, I’m not sure that we completely know the answer, but we are going to explore this question today in hopes of shedding some light on it.  The good thing is that there is more information coming out all of the time, so I will reserve the right to change my mind as time goes along.

Mechanisms of Bruising

There are several ways that bruising typically occurs as part of the therapy process.  One is via aggressive Instrument Assisted Soft Tissue Mobilization (IASTM).  This usually involves scraping over the skin with some sort of a plastic, jade, or metal tool.  In the case of IASTM, the bruising occurs due to the trauma that is caused by the pressure and repetition of the tools moving over the skin.  The tissue is strained which causes the cells to bleed and eventually leads to blood sitting in the tissue (bruising).

The second major mechanism of bruising within our manual therapy is through decompression.  This usually occurs with cupping and is due to the negative pressure that is created via the cups which pulls blood out of the cells, leaving it in the tissue (bruising).  It is a completely different mechanism, even though it often looks similar.

Is Bruising Therapeutic?

There’s a fair amount of conflicting information on this topic.  The ancient Chinese have said for years that bruising is therapeutic.  They believed that by causing bruising, you actually jump started the inflammatory response which accelerated tissue healing.  This has been the basis of Guasha for many, many years.

In recent years, research has leaned away from bruising with our manual therapy and the aggressive approach that it usually takes to achieve it.  This is likely because of the new understanding of the nervous system’s role in improving pain and performance, as well as the destruction that often occurs to achieve bruising.  This local trauma is usually not advantageous to the healing response and mentally debilitating to patients who undergo these treatments (it isn’t fun to be bruised under any circumstances, but especially on purpose).  As I look over this research, it has steered me away from bruising my patients with IASTM.  I have taken a neurological approach with my tools and I’m still seeing great results.  With regards to IASTM, we now understand that bruising isn’t necessary to see results in the local tissue.

Interestingly, there is also recent research that demonstrates an anti-inflammatory (therapeutic) response to bruising.  It’s a complicated process that I’m not smart enough to fully understand, but the high level overview is that there is an enzyme response that takes place when blood sits in our tissue that actually has an anti-inflammatory effect both on local tissue and the system as a whole.  Essentially when we have a bruise, we are bathing the local tissue in anti-inflammatory enzymes.

Take Home

So, hopefully you aren’t completely confused by now.  Basically as it sits right now, we believe that there is some therapeutic effect to bruising because of it’s anti-inflammatory properties.  But, we have to measure the cost (damage) that it takes to get that bruising to make sure that there is an appropriate risk – reward ratio.

We know that we can improve movement with IASTM without bruising our patients due to the ability to easily stimulate the mechanoreceptors in our skin and fascial network.  And, while bruising may have some anti-inflammatory properties, it usually takes quite a bit of tissue damage and pain to create this bruising effect.  So, in my opinion, bruising our patients with tools on the skin doesn’t have a great risk – reward ratio.

On the other side of this discussion is cupping.  It does often cause bruising, but without the same trauma and pain to local tissue.  While I do think that there are some exciting neurological things that we can do with cupping, at this point, I don’t think that they are quite as effective as IASTM at changing fascial tone, but I love cupping for the local decompression of tissue and enzyme response.

The Right Tool at the Right Time

As always, I do reserve the right to change my mind going forward, but at this point, my philosophy with regards to manual therapy is this:

• IASTM:  I use it to change fascial tone, reduce pain, treat nerve entrapments and work to improve how they think, feel and move.  My main focus with tooling is to treat the nervous system while avoiding bruising as much as possible.
• Cupping:  I am utilizing cupping for the mechanical decompression that takes place with the negative pressure that exists inside the cup.  Therapeutic bruising can (and often should) take place with cupping in an effort to bathe the local tissue in anti-inflammatory enzymes.

The tool that I choose is decided by the patient’s dysfunction, their tolerance to specific techniques and my preferred intervention at that moment.  Use bruising to your advantage, when appropriate.