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Pathology, Contraindications, Areas of Caution, Special Populations (14%)

This is Chapter 3 of the MBLEx Study Guide — 2026 Edition — one complete chapter, free to read right here; no download, no email. It is the same text as the eBook. When you reach the end, the complete guide is one click away.

We didn't give you the easy intro — this free chapter opens on one of the hardest-working parts of the book, so you can judge the teaching where the exam gets difficult.

This content area is 14% of the MBLEx[1]. Its five parts are A. overview of pathologies; B. contraindications — site-specific, pathology-related, special populations, tools, and special applications; C. areas of caution; D. special populations; and E. classes of medications[1, 2].

It is also the area where the exam most clearly tests safety judgment. A pathology question almost never asks you to diagnose. It gives you a client who reports a condition and asks what you should do: proceed, adapt, avoid an area, postpone, or refer. This chapter teaches you to answer that question the same way every time.

A framework for every contraindication question

Massage is generally low-risk: the National Center for Complementary and Integrative Health (NCCIH) describes the risk of harmful effects as low, while noting rare reports of serious effects such as a blood clot, nerve injury or bone fracture[3]. Some of those cases involved vigorous techniques such as deep tissue massage, or clients at higher risk of injury, such as elderly people[3]. The job of this chapter is to recognize those higher-risk situations.

Clinical massage texts describe contraindications as absolute or relative[4]. For the exam, use four decisions:

  1. Postpone the session (systemic or general contraindication). Massage of any kind could spread or worsen the condition, or the client needs medical attention first. Examples: fever with signs of infection, a suspected blood clot, a contagious skin infection over large areas, signs of a stroke.
  2. Avoid an area (local or site-specific contraindication). The rest of the body can be worked; the affected site cannot. Examples: a fresh bruise, an acute sprain, a localized skin infection, varicose veins.
  3. Adapt (area of caution or relative contraindication). Work, but change pressure, position, duration or technique. Examples: osteoporosis, pregnancy, clients taking blood thinners, diabetes with reduced sensation.
  4. Refer or get clearance. The client needs a health care provider's evaluation or input before or alongside massage. Refer whenever signs are unexplained, severe, or worsening.

Trap: "massage improves circulation, so it will help." If increased circulation could move a clot or spread an infection, the "benefit" is the danger. Always ask what the tissue is doing now.

3A Overview of pathologies

The exam expects working knowledge of common conditions: what they are, what you would see or hear from the client, and what that means for the session. Group them by system.

Circulatory

  • Deep vein thrombosis (DVT) — a blood clot in a deep vein, most often in the lower leg or thigh[5]. It can break loose and travel to the lung as a pulmonary embolism[5]. Sitting still for a long time raises the risk[5]. Signs include warmth and tenderness over the vein, pain or swelling, and skin redness[5]. Decision: do not massage the area; with any suspicion of a DVT, postpone and refer the client for immediate medical evaluation.
  • Varicose veins — swollen, twisted veins visible under the skin[6], caused when weak or damaged valves let blood pool[6]. Decision: avoid direct pressure on the veins; light work around them is usually acceptable.
  • High blood pressure (hypertension) — usually has no symptoms[7]. Decision: adapt. Ask whether it is controlled and whether medication causes dizziness; help the client up slowly.
  • Atherosclerosis — plaque builds up inside arteries[8]. It is associated with heart disease and stroke; caution with vigorous work on the neck and limbs.
  • Stroke — a loss of blood flow to part of the brain[9]. If you think a client is having a stroke, call 911 right away[9].
  • Edema — swelling from fluid in the tissues[10], with causes that range from too much salt to heart failure or kidney disease[10]. Decision: unexplained edema needs medical evaluation before massage; the cause decides whether massage is appropriate.

Lymphatic and immune

  • Lymphedema — swelling from lymph building up in soft tissues[11]. Treatment can include exercise, compression, skin care and massage[11]. Manual lymphatic drainage (MLD) is gentle massage that helps move lymph[12]; it is part of complete decongestive therapy managed by a certified lymphedema therapist[12]. Decision: adapt and coordinate; deep pressure on a lymphedematous limb is inappropriate, and specialized MLD requires specific training.
  • Autoimmune conditions — the immune system attacks healthy cells by mistake[13]. Rheumatoid arthritis (RA) is an autoimmune arthritis causing pain, swelling and stiffness in joints[14]. Decision: avoid inflamed joints during a flare; gentle work is often welcome between flares.

Musculoskeletal

  • Osteoarthritis (OA) — the joint cartilage breaks down and becomes rough[15]. Different from RA: OA is wear-related; RA is autoimmune.
  • Osteoporosis — bones become weak and likely to fracture[16]. It is a "silent" disease, often without symptoms[16]. Decision: adapt pressure; avoid heavy pressure, especially over the ribs and spine.
  • Gout — uric acid builds up over time[17]; flares often begin in the big toe or a lower limb[17]. Decision: avoid a joint in an acute flare.
  • Sprain and strain — a sprain is a stretched or torn ligament[18]; a strain is a stretched or torn muscle or tendon[18].
  • Tendinitis — often follows repeated injury to an area[19]. Bursitis — an inflamed bursa[20], usually at the knee or elbow[20].
  • Plantar fasciitis — inflammation of the plantar fascia, the thick tissue from the heel to the toes that forms the arch[21].
  • Frozen shoulder — the shoulder is painful and loses motion because of inflammation[22] of the joint capsule.
  • Torticollis — the neck muscles tilt or turn the head to one side[23].
  • Shin splints — inflammation of the muscles, tendons and bone tissue around the shin[24]. Osgood-Schlatter disease — painful swelling of the bump just below the knee[25], seen in growing adolescents.
  • Fibromyalgia — a chronic condition with widespread pain and fatigue[26]. NCCIH reports a review finding that massage continued for at least five weeks improved pain, anxiety and depression in fibromyalgia[3]. Decision: adapt — lighter pressure, attention to post-session soreness.

Postural deviations

  • Kyphosis — an increased rounding of the back that leads to a hunchback or slouching posture[27].
  • Lordosis — the inward curve of the lumbar spine; a small degree is normal, and too much is called swayback[28].
  • Scoliosis — a sideways curve of the spine[29]; signs include leaning to one side and uneven shoulders and hips[29].

Nervous system

  • Multiple sclerosis (MS) — damages myelin, the protective coating around nerve cells[30].
  • Parkinson's disease — nerve cells do not produce enough dopamine[31]; symptoms include trembling, stiffness, slowness of movement and poor balance[31]. Decision: adapt; help with transfers on and off the table.
  • Bell palsy — thought to result from inflammation of the facial nerve[32]; symptoms are almost always on one side of the face only[32].
  • Nerve compression syndromes. In carpal tunnel syndrome a nerve in the wrist is squeezed[33] — the median nerve[33], which supplies feeling to the thumb and first three fingers[33]. In thoracic outlet syndrome nerves and vessels passing near the shoulder and collarbone are compressed[34], causing neck and shoulder pain, finger numbness and tingling, and a weak grip[34]. Sciatica is a symptom of a problem with the sciatic nerve, the largest nerve in the body[35], and can extend from the lower back down the leg[35].
  • Tension headache — due to tight muscles in the shoulders, neck, scalp and jaw[36].

Endocrine

  • Diabetes — blood glucose is too high[37]; symptoms can include numbness or tingling in the feet or hands and sores that do not heal[37]. Decision: adapt. Reduced sensation means the client may not feel excessive pressure or heat; avoid recent insulin injection sites; keep fast-acting carbohydrate such as juice on hand, because low blood sugar is common in people who take insulin[38].

Respiratory

  • Asthma — the airways become inflamed and narrowed[39]. Decision: adapt position (semi-reclined if lying flat is uncomfortable), avoid strong scents, and know where the client keeps their inhaler.

Skin and contagious conditions

ConditionCause and spreadDecision
Herpes simplex (cold sores)Virus; spreads through direct contact[40]Avoid the area; postpone if lesions are widespread
ShinglesChickenpox virus; its rash fluid can spread chickenpox by direct contact[41]Avoid the rash; it is very painful
Tinea (ringworm, athlete's foot)Fungus; spread by touch and damp surfaces[42]Avoid the area; postpone if extensive
ImpetigoBacteria[43]; spreads by contact with sores[43]Postpone until treated
CellulitisInfection of skin and deeper tissue[44]; fever, chills, red tender skin[44]Postpone and refer
ScabiesMite; prolonged skin-to-skin contact[45]; shared towels and bedding[46]Postpone; launder linens
MRSABacteria; contact with infected people, wounds or objects[47]Postpone active infections; strict hygiene
LiceClose person-to-person contact[48]Postpone until treated

Trap: "it's only on one small area." A single covered cold sore on the lip is a local contraindication. Impetigo, scabies or lice are not local: they spread through the linens and the practitioner's hands, so the whole session waits.

3B Contraindications

The outline sorts contraindications into five kinds[1]. Learn one example of each.

  • Site-specific. The problem is in one place: a bruise, a fresh sprain, a varicose vein, an open wound, a skin lesion. Work elsewhere.
  • Pathology-related. The condition itself changes the plan for the whole body: DVT, fever, uncontrolled high blood pressure, acute infection, recent surgery.
  • Special populations. The person's stage of life or situation changes the plan: pregnancy, older adults, infants, clients with cancer, clients with disabilities.
  • Tools. Implements such as hot stones, massage tools and mechanical devices concentrate pressure or temperature and add their own contraindications: sensation loss, fragile skin, varicose veins, bony areas.
  • Special applications. Hot and cold applications, hydrotherapy and topical products such as essential oils have separate contraindications. Aromatherapy oils are inhaled or applied diluted to the skin[49]; ask about allergies, asthma and skin sensitivity before using any product.

3C Areas of caution

Areas of caution (sometimes called endangerment sites) are places where nerves, blood vessels or organs lie close to the surface or are poorly protected, so deep or sustained pressure could injure them. Pulse points are a useful map: common sites to find a pulse include the temporal and facial arteries, the brachial arteries in the upper arm, the femoral arteries in the thigh and the popliteal arteries behind the knee[50] — a pulse you can feel is an artery close enough to press on.

AreaWhat is there
Anterior neckCommon carotid arteries, which branch from the aortic arch region[51] and supply the brain[50]; the jugular veins
Axilla (armpit)Axillary artery, continuing into the brachial artery of the upper arm[51]; the brachial plexus, which supplies nerves to the arm[52]; lymph nodes[53]
Medial upper armBrachial artery[50]
Femoral triangle (anterior upper thigh)Femoral artery[50]; inguinal lymph nodes[53]
Popliteal fossa (back of knee)Popliteal artery[51] in the diamond-shaped space at the back of the knee[54]
Lower back near the lower ribsKidneys, only partly protected by the eleventh and twelfth ribs[55]
Xiphoid processForceful pressure can drive it into the liver[56]

How it is tested. Expect "which technique is most appropriate in the popliteal fossa?" The right answer is light, broad, non-specific contact — never deep, sustained point pressure.

3D Special populations

Pregnancy

A systematic review of relaxation massage in pregnancy advises that massage be performed in a side-lying (lateral) position if the client is lying down, with seated positions also possible[57]. Pregnant clients should not remain supine for an extended period, to prevent vena cava syndrome[57]. For complicated or high-risk pregnancies, the review advises consulting the obstetrician and deciding case by case[57]. Varicose veins are more common in pregnancy[6], and the hormone relaxin affects the body's preparation for childbirth[58]. Decision: side-lying or semi-reclined positioning, bolsters, no deep pressure on the legs, and clearance from the prenatal provider for high-risk pregnancies.

Older adults

Reported serious injuries from massage have included cases in clients at higher risk of injury, such as elderly people[3]. Thinner skin, osteoporosis[16], medications and reduced sensation all call for lighter pressure, careful transfers, and time to sit before standing.

Clients with cancer

With appropriate precautions, massage can be part of supportive care for people with cancer[3]. Therapists may need to use less pressure in areas sensitive because of cancer or its treatment[3]. A 2026 systematic review concluded that light to moderate intensity massage can be performed in people living with or receiving treatment for cancer without increased risk of harm[4]. Decision: adapt, don't refuse: coordinate with the care team, avoid tumor sites, radiation-treated skin, ports and lymphedema-prone limbs, and use lighter pressure.

Infants and children

NCCIH reports evidence that premature babies who are massaged may have improved weight gain[3]. Work with minors requires a parent or guardian's consent and, in most settings, their presence.

Clients with disabilities or chronic conditions

Adapt positioning, communication and transfers; ask the client how they prefer to be assisted. A wheelchair user may be massaged seated. A client who has had a stroke may have reduced sensation on one side.

Sources cited in this excerpt

  1. MBLEx Candidate Handbook (effective September 17, 2026), reading-order text. Federation of State Massage Therapy Boards (FSMTB), 2026-09-17. https://fsmtb.org/wp-content/uploads/2026/09/MBLEx-Candidate-Handbook-2026.pdf
  2. MBLEx Content Outline (© FSMTB 2023), reading-order text. Federation of State Massage Therapy Boards (FSMTB), 2023. https://fsmtb.org/wp-content/uploads/2025/12/MBLEx-Content-Outline.pdf
  3. Massage Therapy: What You Need To Know. National Center for Complementary and Integrative Health (NIH), May 2019. https://www.nccih.nih.gov/health/massage-therapy-what-you-need-to-know
  4. Harms of massage in persons with cancer or receiving treatment for cancer: A systematic review and meta-analysis. PLOS One (via PubMed Central), 2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC13440881/
  5. Deep Vein Thrombosis | DVT | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, November 20, 2025. https://medlineplus.gov/deepveinthrombosis.html
  6. Varicose Veins | Spider Veins | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, June 27, 2025. https://medlineplus.gov/varicoseveins.html
  7. High Blood Pressure | Hypertension | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, January 22, 2026. https://medlineplus.gov/highbloodpressure.html
  8. Atherosclerosis | Arteriosclerosis | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, November 23, 2025. https://medlineplus.gov/atherosclerosis.html
  9. Stroke | CVA | Cerebrovascular Accident | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, July 28, 2025. https://medlineplus.gov/stroke.html
  10. Edema | Dropsy | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, August 23, 2025. https://medlineplus.gov/edema.html
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  18. Strains | Sprains | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, September 22, 2025. https://medlineplus.gov/sprainsandstrains.html
  19. Tendinitis: MedlinePlus. MedlinePlus, U.S. National Library of Medicine, September 1, 2026. https://medlineplus.gov/tendinitis.html
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  23. Torticollis: MedlinePlus Medical Encyclopedia. MedlinePlus, U.S. National Library of Medicine, retrieved 2026-09-24. https://medlineplus.gov/ency/article/000749.htm
  24. Shin splints - self-care: MedlinePlus Medical Encyclopedia. MedlinePlus, U.S. National Library of Medicine, retrieved 2026-09-24. https://medlineplus.gov/ency/patientinstructions/000654.htm
  25. Osgood-Schlatter disease: MedlinePlus Medical Encyclopedia. MedlinePlus, U.S. National Library of Medicine, retrieved 2026-09-24. https://medlineplus.gov/ency/article/001258.htm
  26. Fibromyalgia | FMS | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, February 28, 2024. https://medlineplus.gov/fibromyalgia.html
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  30. Multiple Sclerosis | MS | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, September 17, 2026. https://medlineplus.gov/multiplesclerosis.html
  31. Parkinson's Disease | PD | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, September 29, 2025. https://medlineplus.gov/parkinsonsdisease.html
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  33. Carpal Tunnel Syndrome | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, January 10, 2024. https://medlineplus.gov/carpaltunnelsyndrome.html
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  36. Headache | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, November 19, 2025. https://medlineplus.gov/headache.html
  37. Diabetes | Type 1 Diabetes | Type 2 Diabetes | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, February 3, 2025. https://medlineplus.gov/diabetes.html
  38. Hypoglycemia: MedlinePlus. MedlinePlus, U.S. National Library of Medicine, April 17, 2023. https://medlineplus.gov/hypoglycemia.html
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  40. Herpes Simplex | Genital Herpes | Herpes Simplex 1 | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, August 1, 2024. https://medlineplus.gov/herpessimplex.html
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  43. Impetigo | Strep | Staph | MedlinePlus. MedlinePlus, U.S. National Library of Medicine, June 27, 2025. https://medlineplus.gov/impetigo.html
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  56. Anatomy and Physiology 2e — 19.1 Heart Anatomy. OpenStax, Rice University, 2022-04-20 (publication date); retrieved 2026-09-24. https://openstax.org/books/anatomy-and-physiology-2e/pages/19-1-heart-anatomy
  57. Effects, Side Effects and Contraindications of Relaxation Massage during Pregnancy: A Systematic Review of Randomized Controlled Trials. Journal of Clinical Medicine (via PubMed Central), 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8396946/
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