THERAPEUTIC MODALITIES Monique Mokha, PhD, ATC, Report Editor

Instrument-Assisted Soft Tissue Mobilization

Robert Stow, PhD, ATC, CSCS • University of Wisconsin-Eau Claire

T he Graston Technique® represents a

specific approach to soft tissue manipula-
tion that uses six different stainless steel
instruments (Figure 1) to release scar tissue,
adhesions, and fascial restrictions.1 The tools
used for the Graston Technique® were initially
developed by a competitive water skier who
had a tool and dye background.2 When he
injured his knee and did not respond com-
pletely to therapy, he began to experiment
with various shapes of tools to mimic the
manual techniques of
his therapist in order
Key Points to provide an enhanced
manipulation of his soft
The Graston Technique® can assist the
tissue. From his curios-
clinician with manual therapy assessment
ity, and trial and error
and treatment of soft tissue pathology.
by the therapy staff,
the Graston Technique®
The Graston Technique® is just one part of
the overall rehabilitation program. of Instrument-Assisted
Soft Tissue Manipula-
Patients must be well informed of the tion (ISTM) was devel-
potential effects when using this therapeu- oped. The purpose of
tic approach. this report is to pro-
vide an overview of the
Graston Technique®,
which will include a review of documented
therapeutic outcomes.
(e.g., inflammation, muscle spasms, pain)
or enhancing components of normal mus-
culoskeletal function (e.g., increase range of
motion, increased muscular strength).3 The
principles of the Graston Technique® fits well
with this philosophy; it is one tool that can
be used in the rehabilitation plan to achieve
the desired outcome. In developing this
plan, a systematic approach should be used,
including six sequential steps that should be
followed during the therapy session:1
• Examination
• Warm-Up
• ISTM
• Stretching exercises
• Strengthening exercises
• Cryotherapy
Upon completion of the pretreatment
examination, the targeted tissue area should
be warmed, preferably through cardiovas-
cular exercise. Warm-up of tissues that are
adjacent to the targeted treatment site is
beneficial. Options include use of a stationary

The Graston Technique

Most clinicians agree that there is no single
technique, tool, or modality that will com-
pletely resolve an impairment of musculosk-
eletal function. The goal of therapy is to provide
an optimal environment for healing, by either
modifying physiologic responses to injury Figure 1  Stainless steel instruments.
© 2011 Human Kinetics - ATT 16(3), pp. 5–8

international journal of Athletic Therapy & training may 2011  5

cycle, upper body ergometer, or elliptical trainer. Light
jogging for 5-10 minutes is also beneficial or the admin-
istration of ultrasound, diathermy, or a heat pack. For
example, when treating plantar fasciitis, the Achilles
tendon and the posterior lower leg musculature could
be warmed through 5-10 minutes on a stationary cycle.
After the warm-up, the ISTM treatment is administered.
Subsequently, targeting stretching and therapeutic
exercise should be performed. Both of these reha-
bilitation procedures are necessary to promote tissue
lengthening and collagen fiber realignment, which help
to prevent the released tissue from becoming restricted
again. The treatment session should be concluded with
cryotherapy, which may be substituted with heat or
some other modality, depending on the specific nature
of the patient’s condition.
When deciding if ISTM might provide an effective
treatment option, the etiology of the injury and the
type of pathology must be considered. Table 1 outlines
indications for use of ISTM, which is primarily focused
on soft tissues; however, not all soft tissue pathologies
can be effectively treated through ISTM. Currently, the
benefits derived from ISTM include release of fascial
restrictions, breakdown of collagen cross-linkages,
increased blood flow, and possibly an increase in
regenerative cellular activity.1,4-6 Even with the greatest
care, however, there are potentially adverse treatment
responses to ISTM that may occur. The patient may
experience discomfort during administration of the
treatment, and petechiae (i.e., bruising) may become
apparent during or after the treatment (Figure 2).
Bruising results from localized trauma, which may be
associated with separation of adhesions from healthy
tissue.4 Personal clinical experience has shown that the
cervical region, lateral thigh, anterior pelvic regions,
and posterior calf appear to be most sensitive during
administration of ISTM. Although discomfort and bruis-
ing may be experienced, patients who have realized
a decrease in symptoms have returned repeatedly
for additional ISTM sessions. The patient must be
informed about the potential effects and benefits of
the treatment, and other therapeutic modalities should
be administered for pain management. See Table 2 for
precautions and contraindications.
Instruments
The Graston Technique® instruments have either a
convex or a concave shape. The concave shape allows
for the pressure applied by the clinician to be dispersed
over a large area, thereby promoting comfort during
treatment. The convex shape concentrates pressure
over a smaller surface area, which may cause greater
patient discomfort, but allows the clinician to focus on
a defined specific area of tissue. The instruments have
either a single-beveled edge or double-beveled edge.
The GT-2 and GT-6 instruments have a double-beveled

Table 1. Instrument-Assisted
Soft tissue mobilization:
possible indications 1,4
Indications
Medial & Lateral Carpal Tunnel Syndrome
Epicondylosis
Neck & Back Pain Plantar Fasciitis
Rotator Cuff Tendinosis Tibialis Posterior
Tendinosis
DeQuervain’s Syndrome Post-Surgical & Traumatic
Scars
Myofascial Pain & Chronic & Acute Sprains/
Restrictions Strains
Non-Acute Bursitis RSD (Reflex Sympathetic
Dystrophy)
IT-Band Syndrome Wrist Tendinosis
Reduced ROM Achilles Tendinosis
due to Scar Tissue Figure 2  Adverse treatment responses to ISTM.

6  may 2011 international journal of Athletic Therapy & training

 to both hind legs. Thirty-one of the animals received
Table 2. Instrument-Assisted
instrument-assisted cross-fiber massage treatment
Soft Tissue Mobilization:
three times per week for three weeks to one extremity
Precautions and
(i.e., the other was untreated), and 20 animals received
Contraindications1,4
the same treatment for 10 weeks to one extremity. At
Precautions Contraindications four and 12 weeks postinjury, MCLs were harvested
Anti-coagulant medica- Open wound (unhealed for testing. The nontreated MCLs were noted to have
tions suture site) more adhesions and granular tissue, which made the
Cancer Unhealed fractures harvesting process more challenging.5 In comparison
to nontreated MCLs at four weeks postinjury, the
Varicose veins Thrombophlebitis
treated MCLs had 43.1% greater tensile strength,
Burn scars Uncontrolled hypertension
39.7% greater stiffness, and were able to absorb 57.1%
Acute inflammatory Patient intolerance/ more energy before failure. At 12 weeks postinjury, the
conditions hypersensitivity treated MCLs were 15.4% stiffer than the nontreated
Kidney dysfunction Hematoma ligaments, but there was no significant difference in
Inflammatory condition Osteomyelitis tensile strength or energy absorption to failure. The
secondary to infection treated ligaments demonstrated greater cellularity
Rheumatoid arthritis Myositis ossificans and better collagen fiber alignment when compared
to the nontreated ligaments at weeks 4 and 12. The
Pregnancy Hemophilia
nontreated ligaments demonstrated greater scarring
and more poorly organized collagen, especially at four
weeks postinjury.
edge, which limits the depth of tissue penetration.
Use of ISTM was reported in a case study that
Because this design is tolerated well by the patient, it
involved a 59-year-old man with a one-year history of
can be used in sensitive areas, and it is appropriate for
intense low back pain (i.e., subactue lumbar compart-
treatment of areas that do not allow a for full-stroke
ment syndrome) that caused him to miss two to three
movements. The single-beveled edge is used to obtain
days of work every two to three months.8 His initial
greater tissue penetration and separation of subcuta-
treatment protocol consisted of bed rest and analgesics.
neous tissues.
His pain was managed well enough to allow him to
Therapeutic Outcome work as a shoe salesman until he experienced pain that
would not subside, and that prevented performance of
Research evidence that documents the effectiveness his activities of daily living for a period of two weeks.
of ISTM is limited; however, several experimental ISTM treatments were administered to the hamstrings,
and case studies have produced positive findings. sacrum, right hip lateral rotators, and low back region.
McLaughlin7 investigated the effectiveness of ISTM The patient received six treatment sessions (twice per
for reduction of edema associated with ankle sprains. week for three weeks), and each included performance
Participants were intercollegiate, intramural, and high of two sets of three stretches to the affected area after
school athletes. They were randomly assigned to either administration of ISTM. The patient was instructed
a traditional edema control protocol or a traditional to perform the stretches at home between treatment
edema control protocol that was combined with ISTM. sessions. After the six sessions, the patient was asymp-
There was no significant difference in edema control tomatic and able to complete all tasks necessary for
between the two groups (i.e., both therapeutic protocols daily living and work.
were equally effective in reducing edema). Achieve-
ment of full weight-bearing status for the group that
received ISTM averaged one day sooner than that for Summary
the comparison group, however. Training expenses and the cost of the instruments are
Loghmani and Warden5 assessed short-term and the primary limitations to widespread utilization of
long-term effects of ISTM on healing of the medial ISTM. Also, the time required to attain skill mastery
collateral ligament (MCL) in an animal model. Fifty- in the use of the instruments limits the number of
one rats had bilateral MCL injuries surgically induced clinicians who can use it effectively, which limits the

international journal of Athletic Therapy & training may 2011  7

accumulation of evidence to support its use. ISTM is
not a magical cure for all ills; it must be used in con-
junction with other therapeutic procedures for its full
benefits to be realized.
Athletic trainers and therapists who are interested
in learning ISTM can access information at www.
grastontechnique.com, or by calling 888.926.2727.
Graston Technique® training is offered at various loca-
tions throughout the United States, Canada, and Eng-
land. Completion of two training modules is required
for certification (i.e., Module 1, Basic Training and
Module 2, Upper/Lower Extremities and Spine). 
3. Starkey, C. Therapeutic Modalities. 3rd ed. Philadelphia, PA: F.A. Davis;
2004.
4. Hammer WI. The effect of mechanical load on degenerated soft tissue.
J Bodywork Move Ther. 2008;12:(3):246-256.
5. Loghmani MT, Warden SJ. Instrument-assisted cross-fiber massage
accelerates knee ligament healing. J Orthop Sports Phys Ther. 2009;
39:(7):506-514.
6. Carey MT. Graston Technique Instruction Manual, 2nd ed. Indianapolis,
IN: TherapyCare Resources INC; 2001.
7. McLaughlin, E. An Evaluation of the Effectiveness of the Modified Graston
Technique on Reducing Edema Following an Acute Ankle Sprain [master’s
thesis]. Bloomington, IN: Indiana University; 2006.
8. Hammer, W., Pfefer, M. Treatment of a case of subacute lumbar
compartment syndrome using the graston technique. J Manipulative
Physiol Ther. 2005, 28(3):199-204.

Robert Stow is an assistant professor and director of the athletic

References training education program in the Department of Kinesiology at the
University of Wisconsin - Eau Claire and is certified in the use of the
1. Carey-Longmani, MT, Hammer. WI. Graston Techniqueâ In: Hammer, Graston Technique.
WI, ed. Functional Soft-Tissue Examination and Treatment by Manual
Methods. Boston, MA: Jones and Bartlett; 2007: 589-625.
2. Graston Technique. History of the Graston Technique Page. http://
grastontechnique.com/AboutUs/CompanyHistory.html. Accessed
March 29, 2010.

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