Are Graston and Active Release Technique (ART) a Legitimate Treatment For Running Injuries?
Soft tissue injuries are the broadest and most common category of injuries that runners suffer from. This category encompasses all injuries to the muscles, tendons, and fascia in your lower body.
While they are often easier to treat and less severe than “bony” injuries like stress fractures, soft tissue injuries like Achilles tendonitis, plantar fasciitis, and muscle strains nevertheless cause huge disruptions in the training of many runners.
As such, any progress on treating these injuries is sure to garner a lot of attention.
Two relatively new treatment protocols, Graston Technique and Active Release Technique (ART), have emerged as popular ways to speed the healing process from muscle, tendon, and fascia injuries, especially in the running and triathlon communities.
But what kind of scientific support do these treatments have, and are they grounded on good medical information?
To answer that, we will have to review some of the scientific literature that has been published on Graston and ART.
Graston and ART: An overview
Before doing that, however, we ought to become familiar with both Graston and Active Release Technique. Both of these treatments are based on the idea of tissue adhesion and scar tissue—according to proponents of ART and Graston, injured tissue develops abnormalities when it heals, which impair normal function.
To get rid of these abnormalities, ART and Graston both use mechanical force to break them down—ART involves the practitioner using his or her hands to apply pressure to the muscles surrounding the injured area, while flexing and extending the joints they are connected to.
Graston involves using curved metal tools to apply pressure and friction across the injured muscle, fascia, or tendon. Both are “proprietary” techniques, meaning that a practitioner must pay for special classes to become licensed in them.
This naturally attracts some skepticism from the medical and scientific communities, as the nature of the respective businesses, which oversee ART and Graston is somewhat out-of-step with treatments under serious consideration for rehabbing injuries. Perhaps because of this, most practitioners of ART and Graston are chiropractors, though some physical therapists are licensed as well.
Are Graston and ART based on legitimate principles?
Structural changes in tissues affected by chronic overuse injuries are well-documented: The collagen fibers of the Achilles tendon, for example, which appear like wavy, parallel lines when healthy, rupture, snarl, and degenerate into a mess that looks like a plate of spaghetti in athletes with chronic Achilles problems. And the formation of scar tissue in muscle injuries is well-documented, as well.
Additionally, successful treatment of tendon injury through well-vetted rehab programs, such as eccentric heel drops for Achilles tendonitis, is connected with a return to normal tendon structure, at least as measured by ultrasound imaging.
Unfortunately, there’s no good evidence yet that ART or Graston (or any soft-tissue manipulation therapy) can influence the microscopic structure of a healing tendon or muscle in an athlete.
Two studies using different manual techniques found some changes in the structure of rat tendons and ligaments, but this is not nearly enough to declare the theoretical foundations of ART and Graston to be sound.
The best science on these therapies so far is limited to case studies and pilot studies. A case study is the scientific equivalent of an anecdote—they describe how a doctor or therapist treated one particular patient with an injury. Pilot studies are generally conducted with only a few subjects and no control group.
In one example, 20 men took a sit-and-reach test for hamstring flexibility, then had ART administered and underwent another sit-and-reach test, which showed an improvement in hamstring flexibility. In another study, five subjects with carpal tunnel syndrome were treated with ART over a period of two weeks and all demonstrated improvement.
Not all pilot studies found success, though—one study of nine athletes with “anterior knee pain” (likely patellofemoral pain syndrome or ‘runner’s knee‘) found that administering one treatment of ART did not result in better knee function.
All peer-reviewed studies on Graston technique to date are limited to case studies, describing individual patients being treated for everything from trigger finger to low back pain.
Breaking the barrier
The biggest barrier to ART and Graston being accepted as legitimate treatments for injury is the lack of well-designed studies on their usefulness. Control groups, which are administered a fake treatment, are absolutely necessary to establish the scientific worth of any injury rehab protocol. Otherwise, factors like the placebo effect and simple healing over time make determining the use of a treatment near-impossible.
While having a scientific basis for treatments is important, the old adage that “any medicine that works is good medicine” holds up.
Today, most insurance companies will pay for chiropractic adjustments for low back pain, not because chiropractic is necessarily based on solid science, but because well-designed placebo-controlled studies have demonstrated that it is a legitimately beneficial treatment for back pain.
While popular among athletes, the usefulness of ART and Graston is still questionable from a scientific perspective. If you think you might benefit from them, feel free to try it out, but do realize that you are taking a gamble on an uncertain treatment. If you are skeptical, you may want to wait until better-designed studies are published on the benefits of soft-tissue manipulation.
1. Kääriäinen, M.; Järvinen, T.; Järvinen, J.; Kalimo, H., Relation between myofibers and connective tissue during muscle injury repair. Scandanavian Journal of Medicine & Science in Sports 2008, 10 (6), 332-337.
2. Öhberg, L.; Lorentzon, R.; Alfredson, H., Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up British Journal of Sports Medicine 2004, 38, 8-11.
3. Loghmani, M.; Warden, S., Instrument-assisted cross-fiber massage accelerates knee ligament healing. Journal of Orthopaedic & Sports Physical Therapy 2009, 39 (7), 506-514.
4. Davidson, C.; Ganion, L.; Gehlsen, G.; Verhoestra, B.; Roepke, J.; Sevier, T., Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Medicine & Science in Sports & Exercise 1997, 29 (3), 313-319.
5. George, J. W.; Tunstall, A. C.; Tepe, R. E.; Skaggs, C. D., The effects of active release technique on hamstring flexibility: A pilot study. Journal of Manipulative and Physiological Therapeutics 2006, 29 (3), 224-227.
6. Drover, J. M.; Forand, D. R.; Herzog, W., Influence of active release technique on quadriceps inhibition and strength: A pilot study. Journal of Manipulative and Physiological Therapeutics 2004, 27 (6), 408-413.
7. Bronfort, G.; Haas, M.; Evans, R. L.; Bouter, L. M., Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. The Spine Journal 2004, 4 (3), 335-356.