Scraping therapy does appear to help with tendon pain, though the strength of the evidence depends heavily on which type of scraping you’re talking about and which tendon is involved. The strongest results come from surgical scraping of the Achilles tendon, where a recent meta-analysis found that patients’ pain and function scores improved dramatically over follow-ups averaging nearly two years. The picture gets murkier for instrument-based scraping performed in physical therapy clinics. Some trials show clear benefits, while others suggest that scraping may not outperform a sham treatment. Before you decide whether it’s worth trying, it helps to understand what the research actually says and where the gaps are.
Two Very Different Procedures Share a Name
When people say “scraping therapy” for tendon problems, they could mean one of two things, and the distinction matters. The first is a minimally invasive surgical procedure, typically performed under local anesthesia and guided by ultrasound. A surgeon uses a scalpel or needle to scrape away abnormal tissue and small blood vessels on the surface of the tendon. This is most commonly done on the Achilles tendon. The second is instrument-assisted soft tissue mobilization, known as IASTM, which includes brand-name versions like Graston Technique and Astym. In IASTM, a clinician uses specially shaped metal or plastic tools to apply controlled pressure along the skin over a tendon, with the goal of breaking down scar tissue and stimulating the formation of new collagen.
The proposed mechanisms overlap. Both aim to disrupt disorganized or scarred tissue and provoke a healing response. IASTM specifically targets scar tissue from injured soft tissues and aims to promote new collagen formation during the repair process. But the intensity, setting, and invasiveness are very different. Surgical scraping requires an operating room (or at least a procedure suite), while IASTM happens in a physical therapy clinic, usually over multiple sessions. The evidence base for each is separate, and lumping them together leads to confusion about what the research actually supports.
Achilles Tendon Scraping Has the Best Evidence
If there’s one area where scraping therapy has genuinely encouraging data, it’s the Achilles tendon. A 2025 systematic review and meta-analysis pooled seven studies covering 235 patients and 291 tendons. The pooled improvement in VISA-A scores, a standard measure of Achilles tendon pain and function, was about 44 points on a 100-point scale. Before surgery, patients averaged a VISA-A of around 43. After surgery, the average climbed to roughly 93. Nearly all patients returned to their pre-injury activity levels, with return-to-sport rates reaching about 96% across the studies that tracked it. Complication rates were low, under 4%, and revision surgery was needed in fewer than 2% of cases.
These aren’t just short-term improvements that fade. A longer-term follow-up study found that about 93% of patients were still satisfied with the outcome after an extended period, and pain scores had dropped from an average of 74 before surgery to 8 afterward on a 100-point scale. That satisfaction held regardless of whether patients had scraping alone or scraping combined with removal of the plantaris tendon, a small accessory tendon that sometimes irritates the Achilles.
A separate large study reported similar numbers, with pain scores dropping from 73 before surgery to 3 afterward across tendons where patients were satisfied, and roughly nine out of ten patients returning to full Achilles tendon loading activity. In a randomized comparison within that study, open surgery with a scalpel and a less invasive percutaneous approach with a needle produced equivalent results.
It’s worth noting that these studies focused on mid-portion Achilles tendinopathy, the type of chronic tendon pain that sits in the middle of the tendon rather than where it attaches to the heel bone. That’s an important qualifier. Insertional Achilles problems, which occur right at the heel, are a different beast and weren’t the focus of this surgical scraping research.
Structural Changes You Can Actually See
One of the more compelling aspects of the Achilles scraping research is that it doesn’t rely solely on patients saying they feel better. Ultrasound tissue characterization, a technique that can objectively measure how organized the tendon’s internal structure is, showed measurable improvement after scraping. At six months after surgery, the proportion of organized tissue within the tendon increased from about 83% to 91%, while disorganized tissue roughly halved. These changes were consistent across all patients in the study and exceeded the minimum threshold needed to confirm a real structural difference rather than measurement noise.
A separate case series found a similar pattern at two years, with organized tissue climbing from about 80% to 86%. That might sound modest, but it cleared the minimum detectable change threshold and was accompanied by large improvements in pain and function scores. The fact that the tendon’s architecture is actually remodeling, not just feeling less painful, adds biological credibility to the procedure.
IASTM for Tennis Elbow and Other Tendons
Outside of surgical scraping, the instrument-based form of scraping therapy has been studied for several tendon problems, with lateral elbow pain (tennis elbow) being one of the better-tested applications. A randomized trial compared IASTM head-to-head with extracorporeal shockwave therapy and a control group in people with lateral elbow pain. IASTM outperformed both shockwave therapy and the control group in reducing pain scores, improving grip strength, and lowering Patient-Rated Tennis Elbow Evaluation scores, both immediately after treatment and at a four-week follow-up.
Earlier work using the Graston Technique reported elimination of pain and normalization of functional tests in patients with supraspinatus tendon problems, Achilles tendon issues, and plantar fascia conditions. Those findings are encouraging but come from smaller and less rigorous study designs. The overall pattern for IASTM across various tendons is: patients tend to improve, sometimes substantially, but the quality of the evidence is uneven. Many studies are case reports, case series, or small trials without blinding.
Pairing Scraping with Exercise
In clinical practice, scraping therapy is rarely used alone. Physical therapists almost always combine IASTM with exercise, most commonly eccentric loading exercises where you slowly lower a weight rather than lift it. There’s evidence that this combination may work better than either approach in isolation.
A case report on mid-portion Achilles tendinopathy documented a patient returning to normal activities after five weeks of combined Astym treatment and eccentric exercise, a timeline roughly half of what’s commonly needed with eccentric exercise alone. A broader literature review found that an IASTM-based protocol achieved symptom resolution in about 78% of patients, compared with 41% for eccentric exercise by itself. Even more striking, when patients who hadn’t responded to eccentric exercise were switched to the scraping-based protocol, about 96% eventually achieved resolution.
This doesn’t mean scraping is doing all the work. It’s possible that the mechanical stimulation from scraping tools “primes” the tissue to respond better to the exercise that follows, or that the combination simply hits the problem from two angles. Either way, if you’re considering IASTM, expect your therapist to pair it with a structured exercise program rather than treat scraping as a standalone fix.
The Sham Problem
Here’s where the enthusiasm needs a reality check. One of the trickiest aspects of studying any hands-on therapy is separating the treatment effect from the placebo response. When a clinician spends time working on your painful tendon with an instrument, you expect to feel better. That expectation alone can reduce pain.
A study on chronic ankle instability tested IASTM against a sham version, where the same instruments were applied with minimal pressure and no therapeutic intent. All groups improved in pain scores, but the reductions in the sham group were actually clinically significant, while the real IASTM group’s improvements were not. In other words, the fake treatment worked as well as or better than the real one for pain relief in that particular study.
Some researchers have tried to design better sham controls. One randomized trial on knee osteoarthritis used the same instruments for the sham condition, applying them gently without therapeutic strokes while matching the contact time. This kind of design helps isolate whether the specific scraping technique matters or whether any tool-to-skin contact triggers a response. But these well-controlled sham comparisons remain uncommon in the IASTM literature, which is a real limitation.
The sham problem applies mainly to IASTM, the clinic-based manual therapy version. For surgical scraping, the comparison is typically against the natural course of the condition or against other surgical approaches, and the large, sustained improvements in both pain scores and tendon structure are harder to attribute to placebo alone.
How Scraping Stacks Up Against Other Treatments
People with tendon pain face a confusing menu of treatment options: eccentric exercise, shockwave therapy, dry needling, corticosteroid injections, platelet-rich plasma, friction massage, and more. Where does scraping fit?
For tennis elbow, the randomized trial mentioned earlier found IASTM outperformed shockwave therapy in pain reduction, grip strength, and overall function. That’s a meaningful finding because shockwave therapy has its own evidence base for tendon problems. A meta-analysis comparing shockwave therapy with dry needling found no significant difference between the two for pain relief in tendinopathy, either immediately or at later follow-up. But combining shockwave therapy with dry needling was more effective than shockwave alone. The picture that’s emerging is one where different modalities may work through overlapping but not identical mechanisms, and combining approaches tends to beat using any single one.
For shoulder tendon problems, a trial comparing focused shockwave therapy to deep friction massage for supraspinatus tendinopathy found shockwave therapy superior in pain reduction and range of motion, with large effect sizes. Deep friction massage is mechanically similar to IASTM in some respects, as both involve applying pressure across the tendon, though friction massage typically uses the clinician’s fingers rather than instruments. The finding suggests that for shoulder tendons specifically, shockwave therapy may have an edge over friction-based approaches.
No single modality has emerged as the clear winner across all tendon locations. The practical takeaway is that scraping therapy belongs in the conversation alongside shockwave, dry needling, and exercise-based rehabilitation. It’s not a miracle fix, but it’s not snake oil either. The best treatment likely depends on which tendon is affected, how long you’ve been dealing with the problem, and what you’ve already tried.
Why Your “Tendonitis” Probably Isn’t Inflamed
This is worth a brief detour because it affects how you think about scraping therapy. The word “tendonitis” implies inflammation (the “-itis” suffix), and for decades the assumption was that overused tendons were inflamed and needed anti-inflammatory treatment. Research over the past 20 years has largely overturned that idea. Most chronic tendon pain involves degeneration of the tendon’s collagen structure rather than active inflammation. The correct term is tendinopathy or, more specifically, tendinosis when referring to the degenerative changes.
This distinction matters because scraping therapy’s proposed mechanism aligns much better with a degenerative model than an inflammatory one. The goal isn’t to reduce swelling; it’s to disrupt disorganized scar tissue and trigger a remodeling response that produces healthier collagen. If your tendon problem is truly acute and inflamed, aggressive scraping could theoretically make it worse. Most practitioners won’t use scraping on a tendon that’s in the acute inflammatory phase, typically the first few days to weeks after an injury. The sweet spot for scraping seems to be chronic tendinopathy, the kind that’s been nagging for months and hasn’t responded well to rest or basic physical therapy.
Safety and What to Expect in Practice
Surgical Achilles tendon scraping has a low complication rate. The meta-analysis reported complications in under 4% of tendons and revision surgery in under 2%. Most complications were minor. The procedure itself is performed under local anesthesia, and many patients are weight-bearing the same day.
IASTM in a physical therapy setting carries different, generally milder risks. The most common side effect is temporary redness, bruising, or soreness at the treatment site. Traditional Gua Sha deliberately produces petechiae, those small red or purple spots from broken capillaries under the skin. Modern IASTM techniques typically aim for a therapeutic effect without that degree of bruising, though some redness is normal. The discomfort during treatment can range from mildly uncomfortable to genuinely painful depending on the clinician’s technique and the sensitivity of the area.
A few practical points if you’re considering IASTM:
- Session count: Most protocols involve multiple sessions, commonly two to three per week for several weeks, combined with a home exercise program.
- Cost: IASTM is typically billed as part of a physical therapy visit. Some reviews have described it as a potentially more cost-effective option compared to more invasive procedures, though head-to-head cost comparisons are lacking.
- Self-treatment: Consumer-grade scraping tools are widely available, but the research has been conducted with trained practitioners who know how to control pressure, angle, and treatment duration. There’s no published evidence supporting self-administered IASTM for tendinopathy, and applying too much pressure to an already painful tendon without proper training could aggravate the condition.
When Scraping Might Not Be the Right Call
Scraping therapy, whether surgical or instrument-based, is generally studied in patients with chronic tendon pain that hasn’t responded adequately to standard conservative treatment like rest, physical therapy, and exercise. It’s not typically a first-line approach. If you’ve had tendon pain for only a few weeks, a structured exercise program and load management are still the evidence-based starting point.
Certain conditions also fall outside the scope of what scraping has been tested for. Tendon tears, whether partial or complete, are a different clinical scenario. Systemic inflammatory conditions like rheumatoid arthritis involve a different disease process. And tendon problems driven primarily by biomechanical issues, like a runner whose Achilles pain stems from a sudden spike in training volume, may respond better to load management and gait correction than to any form of tissue treatment.
The research is also largely limited to a handful of tendons. The Achilles and the lateral elbow have the most data. Patellar tendinopathy (jumper’s knee), rotator cuff tendinopathy, and other common sites have far less evidence specific to scraping. That doesn’t mean scraping won’t work for those areas, but it does mean you’d be relying more on clinical judgment than on published trial data. If a clinician recommends scraping for a tendon that hasn’t been well-studied, that’s not necessarily wrong, but it’s reasonable to ask what their experience has been and what the backup plan is if it doesn’t help.