Perhaps a friend has told you about a physical therapist who "popped" their shoulder back into place with a spectacular crack. Stories like these generate as much concern as they do curiosity. Does it hurt? Is it dangerous? Here's the reality: manual therapy is a safe and often useful approach. But it's not magic. It works in a more interesting (and less dramatic) way than most people imagine.

What exactly is manual therapy?

Manual therapy encompasses techniques that physiotherapists apply directly with their hands to your joints, muscles, and tissues. It includes joint mobilization, manipulation, soft tissue work, and myofascial release. It is one of many tools in a physiotherapist's toolbox.

Manual therapy essentially refers to any technique in which the therapist uses their hands to assess and treat your condition. The term encompasses several different approaches, each with its own specific objectives.

Contrary to popular belief, physical therapists do not "put back" anything that is "out of place." Your shoulder is not out of position. Your vertebrae are not misaligned. These simplistic mechanical explanations have been largely abandoned by modern research. Manual therapy works differently, and understanding how it works completely changes the way you perceive these treatments.

To fully understand how manual therapy fits into a comprehensive treatment plan, check out our guide to physical therapy for shoulder pain, which explains the different therapeutic approaches available.

What are the different types of manual techniques?

Manual techniques are divided into four main categories: joint mobilization (gentle, controlled movements), manipulation (rapid movements sometimes accompanied by a cracking sound), soft tissue techniques (targeted therapeutic massage), and myofascial release (sustained pressure on the fascia). Each technique has its specific indications.

Joint mobilizations are slow, progressive movements applied to a joint. The physical therapist grasps your joint and gently moves it in different directions. This is usually comfortable, sometimes even relaxing. The therapist adjusts the intensity according to your tolerance.

Manipulations are rapid, short-range movements that sometimes produce the famous "cracking" sound. This sound comes from gas bubbles forming in the joint fluid (cavitation). The cracking itself has no therapeutic significance. It does not mean that something has been "put back in place" or "unlocked."

Soft tissue techniques target muscles, tendons, and fascia. They are similar to massage, but with specific therapeutic goals. The therapist applies deep pressure to reduce tissue sensitivity and improve circulation.

Myofascial release applies sustained pressure to specific areas. Modern research shows that the effects come more from changes in the nervous system than from physical changes in the fascial tissue.

How does manual therapy actually affect my body?

Manual therapy acts primarily on your nervous system rather than on your physical structures. It modulates pain signals, stimulates pain control mechanisms in your spinal cord and brain, and can temporarily increase your tolerance for movement. These neurological effects explain why it works best when combined with exercise.

For decades, it was believed that manipulations "realigned" the vertebrae and that mobilizations "released" blocked joints. Modern science tells a different story. Manual therapy probably has no significant structural effects. It works through neurophysiological mechanisms, affecting the way your nervous system processes pain signals.

Your spinal cord contains a control system ("gate control") that filters pain signals. Manual techniques provide sensory information (pressure, stretching, movement) that can temporarily "close the gate" to pain signals. This is similar to the reflex of rubbing an area that hurts.

Your brain also has systems that actively reduce pain. Manual therapy can stimulate these mechanisms, triggering the release of natural chemicals that reduce the transmission of pain signals. These effects are not imaginary. They are real, but temporary, biological processes.

Manual therapy can also create a window of opportunity to move differently. If your shoulder hurts when you raise your arm, mobilization could reduce that pain for 20-30 minutes. During that time, you can practice exercises that would otherwise be too uncomfortable and begin to "retrain" your nervous system.

To better understand how shoulder pain works and why these approaches are effective, check out our comprehensive guide to shoulder pain.

What should I expect during a manual therapy treatment?

Expect to feel pressure or stretching, which can sometimes be uncomfortable but is rarely painful. The physical therapist constantly adjusts the intensity based on your reactions. You may hear cracking sounds (these are normal and harmless). After treatment, you may experience mild soreness for 24-48 hours, similar to that felt after a new exercise routine.

Your physical therapist will first assess your condition. They will test your movements, palpate your tissues, and identify sensitive areas. They will then explain what they are going to do and why. A good therapist will take the time to explain and always obtain your consent.

For mobilizations, you lie down on a treatment table in a comfortable position. The therapist will apply rhythmic movements. For manipulations, they will position the joint precisely and apply a quick movement that lasts a fraction of a second. For soft tissue work, expect pressure that may be uncomfortable on sensitive areas. Some intensity is normal (like "good pain"), but sharp pain is not.

Immediately afterwards, you may feel lighter, more flexible, or less pain. These effects usually last from a few minutes to a few hours. Mild soreness within 24-48 hours is common and normal.

Does manual therapy hurt? Should I be afraid of cracking sounds?

Manual therapy should never be painful. Some techniques create a feeling of stretching or uncomfortable pressure, but you always remain in control. Joint cracking is a normal acoustic phenomenon and is not dangerous. It does not mean that something is "breaking" or "popping back into place." Many effective treatments do not produce any cracking.

Fear of manual treatment is understandable. Spectacular videos on the internet show dramatic manipulations that fuel anxiety. Here is the reality: manual therapy performed by a qualified physical therapist is remarkably safe. Serious complications are extremely rare.

The cracking sound comes from cavitation (the formation of gas bubbles in the joint fluid). It is not the bone cracking, nor the cartilage breaking. It is the same mechanism as when you crack your knuckles. Tell your therapist about your preferences. There are almost always alternative techniques that do not involve cracking.

How does manual therapy combine with exercise?

Manual therapy works best as a facilitator rather than as a standalone treatment. It can temporarily reduce pain and improve range of motion, creating a window of opportunity for movement and exercise. Exercise then consolidates these gains and produces lasting improvements. Think "manual + active" rather than "manual OR active."

The effects of manual therapy are usually temporary. Mobilization can reduce your pain for 30 minutes or a few hours. But without exercise, the pain usually returns. However, if you use this window of opportunity to practice movements that were previously too painful, you create more lasting changes. You strengthen the tissues. You improve motor control.

Think of manual therapy as a tool that opens a door. Exercise is what allows you to walk through that door. Research confirms this approach. The studies showing the best results are those where manual therapy is integrated into an active exercise program, not used alone.

Is manual therapy supported by scientific evidence?

Research shows that manual therapy produces short-term benefits for several musculoskeletal conditions, particularly when combined with exercise. It is more effective than no treatment and comparable to other active interventions. However, it does not produce permanent structural changes and is less effective when used alone than in combination with other treatments.

The evidence is mixed. For certain conditions (acute low back pain, certain neck pains, shoulder problems), studies show that manual therapy can reduce pain and improve function in the short term. These benefits are clinically significant for many patients.

However, studies also show that these effects diminish over time if manual therapy is used alone. In the long term, exercise generally produces superior results. The combination (manual therapy + exercise) often performs better than each approach alone.

"Backed by science" does not mean "works for everyone." Some people respond very well. Others derive little benefit. Your physical therapist continually evaluates your response and adjusts the approach. Manual therapy remains a valuable tool. Used intelligently, at the right time, it can facilitate your recovery. It is a temporary facilitator, not a permanent solution.

Manual therapy: one tool among many

There is nothing mysterious about manual therapy. It is a safe approach that primarily acts on your nervous system. It can temporarily reduce pain and create a window of opportunity for movement. But it works best as part of a plan that includes exercise and active movement.

You don't need to be "repositioned" or "realigned." You need to move, strengthen yourself, and understand your condition. Manual therapy can facilitate this process. That is its true role.