TMR Non-Drug Therapy 2018 March; 1(1): 2-8

Review

The clinical progress and potential mechanism of massage therapy on knee

osteoarthritis
Si-Jia Dong1, Chi Zhang2*, Jia-Hang Wu1, Hao Yin3
1
Hospital of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China. 2Department of
Chinese Medicine Orthopedics, Chengdu University of Traditional Chinese Medicine, Chengdu, China. 3Ziyang Hospital
of Traditional Chinese Medicine, Ziyang, China.

*Correspondence to: Chi Zhang, Department of Chinese Medicine Orthopedics, Chengdu University of Traditional
Chinese Medicine, Chengdu, China. E-mail: zhangchid@126.com.

Highlights Editor’s Summary

The effectiveness of massage is superior to that of Massage plays a key role in the non-drug therapy of
joint cavity injection while the integrated therapeutic knee osteoarthritis.
method containing massage is superior to that of
single massage.

Citation: Dong SJ, Zhang C, Wu JH, et al. The clinical progress and potential mechanism of massage therapy on knee
osteoarthritis. TMR Non-Drug Therapy 2018, 1(1): 2-8
DOI: 10.12032/TMRND201801002
Submitted: 25 November 2017, Accepted: 12 December 2017, Online: 28 January 2018.

Submit a manuscript: http://www.tmrjournals.com TMR Non-Drug Therapy | March 2018 | vol. 1 | no. 1 | 2
 TMR Non-Drug Therapy 2018 March; 1(1): 2-8

Abstract
Knee osteoarthritis (KOA) is a disease due to the degenerative pathological change of knee joint, which commonly
occurs in the elderly. The main clinical characters of KOA are the pain, stiffness, and dysfunction of knee joint. Western
medicine regarding to the treatment of KOA aims to relieve the pain and delay the progress of disease such as
intra-articular injection and functional exercise. Traditional Chinese medicine (TCM) therapy includes massage, herb,
acupuncture, microwave, etc. Among them, the massage technique has the advantages of simpleness, effectiveness and
non-invasive manipulation. The present study compared the curative effects of different therapies on KOA including
Western medicine therapeutic method, single massage, complementary TCM therapeutic method containing massage and
integrated TCM and western medicine therapeutic method containing massage. We found that the effectiveness of single
massage method is better than that of joint cavity injection. The effectiveness of massage in combination with herb and
acupuncture is better than that of massage alone. The effectiveness of joint cavity injection or functional exercise
combined with massage and acupuncture is better than that of the single articular cavity injection or functional exercise.
However, more research and clinical trials are still needed to determine the exact mechanism of massage.
Key words: Knee osteoarthritis, Massage, Review

摘要

膝骨关节炎是一种以膝关节退行性病理改变为基础的疾患，多发于中老年人群，以膝关节肿痛、僵硬、
功能障碍为主要临床表现。西医治疗 KOA 旨在缓解疼痛、阻止和延缓疾病进展，包括关节腔注射、功能
锻炼等；中医治法包括推拿、中药、针灸、微波等，其中推拿手法具有操作简便、疗效明显、无创的特点。
本文通过综述西医治疗方法、单纯推拿手法、包含推拿的中医综合治疗方法、包含推拿的中西医结合治疗
方法治疗膝骨关节炎的临床研究，发现单纯推拿手法的疗效优于关节腔注射；配合中药、针灸的推拿手法
的疗效优于单纯推拿手法；配合推拿手法、针灸的关节腔注射或功能锻炼的疗效优于单纯的关节腔注射或
功能锻炼。但是关于推拿手法治疗膝关节炎的机制报道较少，有待于进一步研究。
关键词：膝骨关节炎；推拿；综述

Abbreviations: KOA, Knee osteoarthritis; TCM, Traditional Chinese medicine; WM, Western medicine.
Funding: This study was supported by Science and Technology Support Program of Sichuan Province (2016KZ0030),
Education Department Support Program of Sichuan Province (15ZA0096).
Competing interests: The authors declare that there is no conflict of interests regarding the publication of this paper.
Copyright: © 2018 TMR Publishing Group. This is an open access article distributed under the terms of the Creative
Commons Attribution Non Commercial License.
Executive Editor: Chang Liu

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Background
Knee osteoarthritis (KOA) is a chronic and progressive
knee joint disease due to the degenerative pathological
change, which has the characteristics of high incidence
and disability. The elderly are prone to suffer from it.
Among people over 50 years old in China, the incidence
of osteoarthritis is second only to cardiovascular disease.
KOA has seriously affected the health and quality of life
of the elderly, giving patients and the society a heavy
financial burden [1]. At present, both the treatment of
KOA with traditional Chinese medicine (TCM) and
Western medicine (WM) have made some achievements.
WM treatment, mainly including analgesic, NSAIDs,
diseases modifying drugs and surgery procedures, is
always accompanied with the occurrence of side effects.
TCM treatment, including health education, medical
exercise, acupuncture, massage, fumigation and hot
compressed with Chinese herbs, etc. are still the main
stream treatment of KOA according to the diagnosis and
management of KOA: Chinese medicine expert
consensus [2]. As one of the non-drug therapies in TCM,
massage has been used to treat disease for more than five
thousand years. The position of massagist appeared as
early as the dynasty of Sui and Tang (B.C. 581~907). It is
known to loosen adhesion of muscle and tendon
ligaments, relieve spasm, and then improving the function
of knee joint [3-5]. There is also evidence that massage
can increase the local blood flow to break the pain cycle,
increase blood flow to the vein or artery, and relieve pain
of the affected area [6-7]. Due to the advantages of simple
operation, remarkable effectiveness and no damage, the
massage has been widely applied in the non-drug therapy
in clinics. The therapeutic method of massage for KOA
mainly include single massage, massage combined with
the methods of TCM and/or WM. Recent relevant
researches are reported as follows.
Single massage therapy
The massage technique contains pushing with one finger,
rolling, pulling out, rotating, patellar rubbing, pressing
and kneading, poking channels manipulation, etc. The
massage therapy not only reduces pain but also in
increases range of motion and extensor muscle strength
[8-9]. Massage also has the abilities of promoting Qi to
activate blood as well as relaxing the tendons and
unblocking collaterals. The underlying mechanism
mainly that it increase the blood flow of knee joint,
improve the blood circulation of joint parts, accelerate the
absorption of inflammatory substances, promote the
penetration and diffusion of slip fluid to articular cartilage,
and promote the metabolism and nutrients supplication of
articular cartilage [10-11].
Yang Ji et al. thought that the essence of KOA was “the
imbalance of mechanical balance” of the knee joint, and
used “six steps and eight methods” (loosing patellar and
subpatellar fat pad, scratching tendons, slicing and cutting,
and so on) for the treatment of KOA. A total of 63 cases
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TMR Non-Drug Therapy 2018 March; 1(1): 2-8
received the therapy and the total effective rate reached
91.67% [12]. Zhu Xiaoqin et al. used massage to treat 82
patients with KOA and compared them with 56 patients
who received the intra-articular injection of sodium
hyaluronate [13]. Massage manipulation containing
kneading knee, deeply rubbing the knee, pressuring knee,
separating tendons, bending and stretching knee, etc. was
performed on patients in the treated group. Study
demonstrated that the effective rates of treated and
control group were 87.80% and 73.21% respectively,
showing significant difference. In a clinical report before
and after Chinese massage treatment (20 cases), the
patients gained significantly faster gait speed, greater step
width, and increased total support time [14].
Complementary treatment of TCM
Massage combined with TCM
Massage combined with oral administration of TCM has
the potential to relax tendons and unblock collaterals,
disperse wind and cold as well as activate blood
circulation to dissipate blood stasis. It also helps to
improve blood circulation around knee joint, promote the
absorption of inflammation, and relieve even eliminate
pain. The specific mechanism is mainly that TCM can
decrease the levels of IL-1β and MMP13 in knee joint,
followed by the decreased inflammation [15].
In addition, hot compress and fumigation-washing of
TCM mediated the effects of both heat and herb, by
which improving the local blood circulation of knee joint,
helping herb penetrate skin, thereby improving the
nutritional status of local bone and soft tissue,
accelerating the absorption of inflammatory edema and
pathological products.
Massage combined with the oral administration of
TCM. Professor Hong thought that treatment of KOA
should make full use of the advantages of TCM
complementary treatment and reduce side effects to the
maximum extent possible. He is good at using the herb
with the function of clearing and activating the channels,
such as of Jixueteng (Caulis Spatholobi), Leigongteng
(Tripterygium), Qiancao (Radix Rubiae) and massage
technique with the effect of warming channels, such as
rolling and rubbing manipulation [16]. There is also
emerging evidence that the WOMAC osteoarthritis index
scores of the treated group given the combination of
massage and TCM (60 patients with KOA) were higher
than that of the control group given 1,
8-Diacetoxy-3-carboxyanthraquinone (60 patients with
KOA), showing significant difference [17].
Massage combined with the external application of
TCM. Huang Guizhong et al. reported that 60 patients
with KOA in the treated group were prescribed the hot
compressing of TCM packet treatment [composed of:
Honghua (Flos Carthami), Danggui (Radix Angelicae
Sinensis), Guizhi (Ramulus Cinnamomi), Wujiapi (Cortex
Acanthopanax Radicis), Luoshiteng (Caulis
Trachelospermi), Qianghuo (Rhizoma et Radix
TMR Non-Drug Therapy | March 2018 | vol. 1 | no. 1 | 4

Notopterygii), Lulutong (Fructus Liquidambaris)] with
supplemental rolling knee method, while 60 patients in
the control group were prescribed voltaren. The effective
rates in the treated group and the control group exhibited
the significant difference after both 6-month (80.0% vs
58.3%) and 12-month treatment (85.0% and 45.0%) [18].
Tan Yanquan et al. performed the WM block therapy (the
control group) of triamcinolone acetonide, lidocaine and
gentamicin and the complementary TCM therapy (the
treated group) on the treatment of KOA, consisting of the
massage manipulation of kneading, point-pressing,
rolling, twisting, rotating, flexion and extension,
acupuncture at the points of Ashi, Xuehai (SP10),
Liangqiu (ST34), Dubi (ST35), Yanglingquan (GB34),
Weizhong (BI40), Kunlun (BL60) points and hot
compressing of herb Ruxiang (Olibanum), Moyao
(Myrrha), Niuxi (Radix Achyranthis Bidentatae), Guizhi
(Ramulus Cinnamomi), Chuanxiong (Rhizoma Ligustici
Chuanxiong), Duhuo (Radix Angelicae Pubescentis),
Sangjisheng (Herba Taxilli), Tougucao (phrymaceae),
Shenjincao (Herba Lycopodii). The total effective rate
was 75% in the control group while that in the treated
group was 92.3%, showing significant difference [19].
Massage combined with fumigation of TCM. In a study
conducted by Hu Dezhi et al, 90 patients with KOA were
divided into the group of Chinese herb fumigation:
Shenjincao (Herba Lycopodii), Tougucao (phrymaceae),
Kuanjinteng (Caulis Tinosporae), Haifengteng (Caulis
Piperis Kadsurae), Honghua (Flos Carthami), Haitongpi
(Cortex erythrinae orientalis), Niuxi (Radix Achyranthis
Bidentatae), Aiye (Folium Artemisiae Argyi), Taoren
(Semen Persicae), common Chuanxiong (rhizoma
sparganii), Sumu (Lignum Sappan)], the group of
massage: point-pressing Dubi (ST35), Xiyan (EX-LE5),
Weizhong (BI40), Xuehai (SP10), Yinlingquan (SP9),
Zusanli (ST36), Yanglingquan (GB34), Chengshan (BL57)
and Ashi and the combined group with Chinese herb
fumigation and massage. The results showed that the
effectiveness of the combined group (92.30%) is superior
to that of single group (66.7% and 63.3% respectively)
[20]. In another clinical report of 61 patients with KOA,
massage combined Chinese herb footbath fumigation and
washing had better clinical efficacy [21].
Massage combined with acupuncture
The method of acupuncture combined with massage has
been widely involved in the treatment of KOA.
Acupuncture could relieve pain while massage could
clear and activate the channels. The combination of them
has been traditionally thought to increase the analgesic
effect, accelerate the circulation of blood and lymph in
the tissue, and adjust the mechanical balance of the knee
joint [22].
Acupuncture. Study has demonstrated that the
effectiveness of combination of acupuncture [Xiyan
(EX-LE5), Dubi (ST35)] and rolling knee manipulation
(45 cases) is superior to that of intra-articular injection of
sodium hyaluronate (45 cases) in patients with KOA
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TMR Non-Drug Therapy 2018 March; 1(1): 2-8
(88.89% vs 62.22%) [23]. There is also evidence that the
effectiveness of treatment group with the combined
treatment of massage manipulation (kneading, pressing,
poking channels and pushing) and acupuncture
[Weizhong (BI40), Shenmai (BL62), Taixi (KI3) and
Mingmen (GV4)] was better than that of control group
with the oral administration of glucosamine sulfate
capsules (94% vs 74%), exhibiting significant difference
[24]. Doctor Jin thought that the incidence of KOA is
associated with the disorder of spleen and stomach
channels. To correct the injury of channels, the
acupuncture at Zusanli (ST36) point and massage of
quadriceps along the spleen and stomach channels were
used.
Warm-acupuncture. The heat effect of warm-
acupuncture has the potential to accelerate the blood and
lymphatic circulation, promote the excretion of
metabolites and the absorption of inflammatory exudates.
Moreover, the combination of warm-acupuncture and
massage could inhibit the regulated upon activation
normal T cell expressed and secreted and monocyte
chemotactic protein-1-mediated inflammatory response
significantly [25].
Warm-acupuncture at the points of Dubi (ST35), Xiyan
(EX-LE5), Yanglingquan (GB34), Liangqiu (ST34),
Xiyangguan (GB33), Heding (EX-LE2), Zusanli (ST36),
Xuanzhong (GB39) and massage method (dissolution,
pushing patella, flexion and extension) were selected for
KOA treatment in 48 patients. The total effective rate
reached 87.5% [26]. 100 patients with KOA were selected
and randomly divided into the control group accepting
TDP light irradiation combined with acupuncture
[Neixiyan (EX-LE4), Dubi (ST35), Xuehai (SP10),
Liangqiu (ST34), Yanglingquan (GB34), Yinlingquan
(SP9), Heding (EX-LE2), Zusanli (ST36) points] and the
treated group accepting massage manipulation (muscles,
pull rotation, push and pull reduction method) combined
with warm-acupuncture at the points above. The results
indicated that the effective rate of the treatment group
was higher than that of the control group, whereas the
onset time and the average treatment times of the
treatment group was lower than that of the control group
[27]. The specific mechanism is that mainly that
warm-acupuncture combined with massage reduce the
level of inflammatory cytokines IL-1β and TNF-α
significantly [28].
Electro-acupuncture. The dense wave in the low
frequency pulse current produces the effect of relieving
pain and the spasm of muscle and blood vessel, which is
suitable for KOA treatment. Studies have demonstrated
that massage and electro-acupuncture can reduce the
content of methane dicarboxylic aldehyde and NO in the
synovial fluid, increase the activity of superoxide
dismutase, inhibit the destruction of free radicals in the
knee joint, and enhance the scavenging capacity of
oxygen free radicals [29].
76 patients with KOA were prescribed the
electro-acupuncture at Xiyan (EX-LE5), Heding
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(EX-LE2), Xuehai (SP10), Liangqiu (ST34), Xiyangguan
(GB33), Zusanli (ST36) and Ashi points with
supplemental massage manipulation (rolling,
point-pressing and kneading). According the results,
electro-acupuncture can effectively enhance the analgesic
effect of massage and the effective rate was up to 85%
[30]. Liu Hongbo et al. applied the massage combined
with electro-acupuncture at Xuehai (SP10), Liangqiu
(ST34), Neixiyan (EX-LE4), Dubi (ST35), Yinlingquan
(SP9), Yanglingquan (GB34), Zusanli (ST36) points in 38
patients. The effective rate was 92.1% using the Lysholm
knee function evaluation table [31].
The integrative therapy of Chinese and WM
containing massage technique.
Intra-articular injection
The specific mechanism of intra-articular injection of
sodium hyaluronate is supplying the endogenous
hyaluronate, eliminating the pain caused by algogenic
substance, improving joint activity, protecting protein
polysaccharide from precipitation and promoting the
biosynthesis of cartilage matrix polymer hyaluronic acid.
Zheng Xiao et al. divided 60 patients randomly into two
groups. The treatment group was given both sodium
hyaluronate knee joint cavity injection and massage
manipulation, while the control group was given the knee
joint injection of sodium hyaluronate. The difference was
statistically significant that the effective rate of treatment
group was higher than that of the control group [32].
Functional exercise
Strength training is a kind of aerobic activity that could
avoid painful arc and not aggravate cartilage load. It can
enhance the strength of quadriceps and the muscles
around the knee joint and promote joint synovial fluid
circulation, improve the nutrition of articular cartilage,
strengthen the stability of the knee joint, and prevent the
knee joint from further injury. According to the knee joint
function assessment standards of Japan's big three
medical school, 78 patients with KOA were divided into
two groups and 39 cases in each one. The treated group
was treated with massage combined with muscle strength
training while the control group was treated with single
massage. After 20 times treatments, the score of the
treated group was higher than that of the control group,
suggesting that muscle strength were closely related to
the joint functional activity [33-34]. In a blind,
randomized controlled trial study of 18 patients with
KOA, the combination exercise-based therapy with
massage therapy may lead to clinical improvement in
patients [35]. In another study conducted by Huang Jian
et al. massage and function training is involved in the
prevention and treatment of KOA via decreasing the level
of IL-1β, TNF-α, methane dicarboxylic aldehyde and
NO while increasing the activity of superoxide dismutase
[29].
The others
Microwave radiation could make full use of the heat
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TMR Non-Drug Therapy 2018 March; 1(1): 2-8
effect and thermal externality effect to achieve the goal of
anti-inflammation and anti-analgesic via prompting
excitability of neuromuscular and improving local blood
circulation and nutrition. Pan Xun et al. reported that
effective rates of control and treated group were 73.4%
and 96.7% while the recurrence rate of those were 40.0%
and 10.0% respectively, in which the control group was
given the knee joint cavity injection of drug while the
treated group was given the complementary of
acupuncture [Futu (ST32), Xuehai (SP10), Dubi (ST35),
Liangqiu (ST34), Xiyan (EX-LE5), Yanglingquan (GB34),
Zusanli (ST36) and Sanyinjiao (SP6), Ashi], kneading
knee manipulation and microwave treatment [36].
Discussion
KOA is also called “arthralgia syndrome”, “heumatism”
and “arthralgia syndrome in knee” in TCM, in which the
deficency liver, spleen and kidney is the foundation and
the invasion of cold dampness, trauma and improper diet
and overtiredness is the inducing factors [37]. Modern
medicine has demonstrated that multiple factors could
result in the occurrence of KOA, such as the metabolic
disorders of synthesis and catabolism of cartilage matrix,
subchondral bone damage and joint inflammation [38].
WM treatment of KOA is still retained at the stage of
symptomatic treatment including oral analgesics, articular
cavity injection of sodium hyaluronate, arthroscopy and
artificial knee replacement, etc. However, these therapies
always lead to the occurrence of adverse reactions and
surgical trauma [39]. Compared with the treatment of
WM, treatment strategies of TCM containing massage is
more accurate, cheaper and safer.
As one of the most important non-drug therapies,
massage method can improve the stability of the knee
joint, relieve joint pain and improve joint stiffness. It also
improves the quality of survival in patients with KOA
[40]. The long-term efficacy of massage has accumulated
considerable experience in the treatment of KOA, and it
has a good prospect for delaying the process of KOA.
The effectiveness of treating KOA with massage is
certain [41]. Massage has the potential to regulate the
body’s physiological and pathological conditions by
touching the specific parts of body surface, achieving the
effectiveness of promoting the circulation of Qi and blood
as well as clearing and warming channels [42]. On the
one hand, the massage acts at the local area of human
body. On the other hand, the force of massage can be
converted into a variety of energy and information and
then has curative effect on the body’s nervous, circulation,
sports system and analgesia through the regulation of
nerves and body fluids [43].
The blockage of channels with phlegm and blood stasis
is responsible for the occurrence of KOA [44]. Massage
therapy can produce the intensive heating effect on the
affected site, by which directly promote the circulation of
Qi and blood of the body. Besides, massage therapy could
promote lymph back-flow, accelerate the absorption of
local blood stasis and inflammatory tissue as well as
relieve the spasm of muscle and tissue, providing a good
TMR Non-Drug Therapy | March 2018 | vol. 1 | no. 1 | 6

foundation for restoration of limb function.
Massage therapy includes variety of methods and each
academic school has its own characteristics. However,
there is a great difference between each other and lack
unified standard. Furthermore, in the previous
experiments, the discussion about the relationship
between the quantity and effect of the massage therapy is
still relatively rare, it is difficult to unify due to the
strength and the time of massage therapy are all
controlled by handlers. The mechanisms of action should
also be further elucidated. In the future work, we should
summarize the massage therapy in all academic schools,
explore the relationship between the quantity and effect,
and develop more research from the levels of cytology,
molecular biology and so on.
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