The Use of Cupping Massage in Musculoskeletal Medicine

The Use of Cupping Massage in Musculoskeletal Medicine

Bronze cupping vessel, Egypt, 300 BCE-300 CE Credit: Science Museum London

Bronze cupping vessel, Egypt, 300 BCE-300 CE Credit: Science Museum London

Cupping has been practiced in most cultures in one form or another throughout history but the true origin of cupping therapy remains uncertain (Qureshi et al 2017). The practice of cupping is a technique where a vacuum is created in a cup, drawing the skin up and decompressing the layers of the epidermis and subcutaneous superficial fascia. 

Cupping massage is a modern version of a traditional therapy, frequently carried out using plastic cups and a manual hand-pump to create the vacuum. The vacuum draws the soft tissue perpendicular to the skin, providing a tensile force, which can be left in one site or moved along the tissue. The practitioner can control the intensity of the desired suction from 80 mmHg to 250 mmHg.

The most common sites of application are the back, chest, abdomen and hips. The cups are typically left in place for 5-15 minutes depending on the client’s reaction and sensitivity. To cover a wider area, cupping massage can also be used with varying amounts of suction.

Why Does Cupping Work?

The responses to cupping are multifactorial - physiological and psychological factors interplay in a complex manner. The biopsychosocial provides a practical framework for investigating the complex interplay between cupping therapy and clinical outcomes.

Based off the biopsychosocial model, investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation. An observed favorable outcome may be explained by a number of overlapping mechanism in the periphery, spinal cord, and brain including, but not limited to:

A manual hand-pump version of cupping

A manual hand-pump version of cupping

  1. Affective Touch - Interpersonal touch and therapeutic stimulation of somatosensory nerves (C-tactile afferent) mediates the release of oxytocin. Which can result in reduced reactivity to stressors and improved mood/affect.

  2. Neuromodulation - The skin, subcutaneous tissue and fascia are all embedded with mechanosensitive nerve fibers, so the application of cupping invokes a number of neurophysiological responses. One being, input from low-threshold Aβ fibers inhibits nociceptive processing and contributes to the activation of endogenous pain inhibitory mechanisms.

  3. Contextual Factors - A positive therapeutic encounter is tied to clinical outcomes, the magnitude of a response may be influenced by mood, expectation, and conditioning.

  4. Mechanical Factors - Gentle stretching of neurovascular structures and muscles induces a molecular response that helps diminish edema and expedite clearance of noxious biochemical by-products of inflammation (cytokines, prostaglandins, and creatine kinase).

Is Cupping Safe?

Cupping is generally considered a safe therapy with minor side effects such as erythema, edema, and ecchymosis in a characteristic circular arrangement. The longer a cup is left on the skin and the higher tensile stress inside of the cup, the more of a circular mark is created this is due to capillary dilation. Cupping encourages blood flow to the cupped region (hyperemia), often the patient may feel warmer and/or hotter as a result of vasodilatation taking place, slight sweating may occur.


Cupping is a technique where a vacuum is created in a cup, drawing the skin and subcutaneous superficial fascia up into the cup. The use of cupping originated as early as 3000 B.C.E in a pre-scientific era and much of the reasoning once used to explain the effects do not make sense in the light of what we know today. Anecdotally cupping is used to alleviate pain, whether cupping works via contextual factors, neurophysiological responses or mechanical factors are all up for discussion.

More to Explore

Aboushanab & AlSanad (2018). Cupping Therapy: An Overview From A Modern Medicine Perspective. J Acupunct Meridian Stud.

Bialosky et al. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther.

Bridgett et al. (2018). Effects of Cupping Therapy in Amateur and Professional Athletes: Systematic Review of Randomized Controlled Trials. J Altern Complement Med.

Chen & Michalsen (2017). Management of chronic pain using complementary and integrative medicine. BMJ.

Courtney et al. (2017). Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther.

Damien et al. (2018). Pain Modulation: From Conditioned Pain Modulation to Placebo and Nocebo Effects in Experimental and Clinical Pain. Int Rev Neurobiol.

Escaloni et al. (2019). Cupping with neural glides for the management of peripheral neuropathic plantar foot pain: a case study. J Man Manip Ther.

Kim et al. (2018). Is cupping therapy effective in patients with neck pain? A systematic review and meta-analysis. BMJ Open.

Ge et al. (2017). Dry cupping for plantar fasciitis: a randomized controlled trial. J Phys Ther Sci.

Leggit, J.C. (2018). Musculoskeletal Therapies: Acupuncture, Dry Needling, Cupping. FP Essent.

Lowe, D.T. (2017). Cupping therapy: An analysis of the effects of suction on skin and the possible influence on human health. Complement Ther Clin Pract.

Murray, D., & Clarkson, C. (2019). Effects of moving cupping therapy on hip and knee range of movement and knee flexion power: a preliminary investigation. J Man Manip Ther.

Pelletier et al. (2015). Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders. Phys Ther.

Qureshi et al. (2017). History of cupping (Hijama): a narrative review of literature. J Integr Med.

Rossettini et al. (2018). Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord.

Rozenfeld & Kalichman (2016). New is the well-forgotten old: The use of dry cupping in musculoskeletal medicine. Journal of Bodywork and Movement Therapies. 

Tham et al. (2006). Cupping: from a biomechanical perspective. J Biomech.

Thompson et al. (2016). Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical Therapy. 

Walker et al. (2017). C-tactile afferents: Cutaneous mediators of oxytocin release during affiliative tactile interactions? Neuropeptides.

Wang et al. (2017). The effect of cupping therapy for low back pain: A meta-analysis based on existing randomized controlled trials. J Back Musculoskelet Rehabil.