Foam rolling as a form of soft tissue mobilization self-treatment has gained popularity during the past decade due to its ease of use and the convenience of not needing a clinician.1 Foam rolling is theorized to relieve tension and tightness in the soft tissue by mobilizing the tissue via friction and mechanical stress.2,3 In theory, foam rolling mechanical stress can positively influence both mechanical (eg, thixotropy) and neuro-physiological (eg, hypothalamic tuning) responses.4,5
Individual athletes and teams often incorporate foam rolling into pre-participation warm-up activities. Recent survey findings indicate that physical therapists often prescribe the use of a rolling massage device before or after exercise in their clinical practice.6 Furthermore, allied health students strongly believe self-myofascial release aids the warm-up before exercise.7 A key goal of any pre-participation warm-up, regardless of whether the physically active population is healthy or pathologic, is to facilitate mobility and increase range of motion (ROM). Although foam rolling has been previously associated with ROM increases,6–8 it is unknown whether integrating foam rolling into a warm-up augments ROM increases. Recent findings8 highlight the need to evaluate the influence of a cardiovascular warm-up on ROM increases attributed to foam rolling when foam rolling interventions take place following cardiovascular activity. The addition of an 8-minute foam rolling intervention or a seated control condition to a 5-minute self-paced jog created ROM increases during baseline measurements before exercise.8 However, there were no differences in ROM between the foam rolling and control conditions.8 To understand the potential additive effects of foam rolling, it is necessary to decipher which ROM changes following a combined light cardiovascular exercise and foam rolling warm-up can be attributed to each activity.
Additionally, practical clinical considerations for integrating foam rolling into a warm-up warrant further investigation. Clinicians have indicated a need for advancing the foam rolling knowledge base. More than 90% of physical therapists responding to a survey evaluating trends in roller massage use indicated that a gap exists in the roller massage literature.6 Although previous findings support the theory that foam rolling increases flexibility, the treatment durations for foam rolling intervention are varied, ranging from 10 seconds to 2 minutes.9–19 To improve clinical decisions regarding treatment duration, comparisons of foam rolling intervention durations are necessary. In addition, evidence indicating the therapeutic effects of foam rolling beyond the time frame immediately after intervention remains inconclusive.10,14,19 To guide clinical practice, data collection procedures should evaluate ROM immediately after the foam rolling intervention and again after a period of time comparable to that between a warm-up and sport participation.
The current study aims to address multiple clinically relevant components of a pre-participation foam rolling intervention to influence ROM, including integration with cardiovascular activity, duration of treatment, and duration of treatment effects. The purpose of this study was to examine whether a single foam rolling session, of either 30 seconds or 2 minutes, has an effect on hamstring flexibility beyond that of a walking warm-up alone. The hamstring muscle group was chosen for its importance in many athletic activities, especially running. We hypothesized that there would be a significant increase in hamstring flexibility, beyond any ROM gains achieved via the walking warm-up alone, in both the 30-second and 2-minute groups immediately after the foam rolling intervention. Our secondary hypothesis was that hamstring flexibility gains would remain 10 minutes after intervention, as indicated by no differences between ROM measures immediately after intervention and 10 minutes after intervention.
A single-blind, randomized design was used to compare the effect of foam rolling on hamstring flexibility. Participants were divided by gender and then randomly assigned to one of three intervention groups: 30-second foam rolling, 2-minute foam rolling, or control (no foam rolling). All participants performed a walking warm-up prior to their assigned intervention. Goniometric hip flexion ROM, the dependent variable, was assessed both immediately after intervention and 10 minutes after intervention.
Forty-nine healthy, physically active participants (14 male, 35 female) were recruited. Physically active was defined as exercising at least three times a week for at least 30 minutes each session.20,21 Participants were required to be familiar with foam rolling, as defined by having used a foam roller at least once in the past 6 months for self-myofascial release purposes. All participants signed an institutional review board approved informed consent statement prior to participation in the screening process for exclusionary criteria. Individuals who exceeded normal ranges of hamstring flexibility, defined as passive hip flexion ROM greater than 130°,22,23 or had sustained a lower extremity injury within the past 6 months that resulted in a stoppage of activity for more than three consecutive workouts (approximately 1 week of physical activity) were excluded from further participation. Participants were included if they had ROM that would be classified as restricted or normal ROM (≤ 130°). These inclusion criteria were selected in an attempt to obtain results that are more comparable to the general athletic population (eg, pre-participation warm-ups involving an entire team).
Of the 49 participants who reported for day 1 testing, 7 were removed due to exclusionary criteria or were unable to complete data collection due to injury or illness. The 42 remaining participants were divided into three groups, comprising 4 males and 10 females, for data collection. The average baseline ROM for all participants was 90.88° ± 14.51° (range: 60° to 124°). There were no differences in patient demographics for day 1 baseline ROM measures between groups (Table 1). All participants reported right leg dominance, which was determined via the leg used to kick a ball.
Patient Demographics (N = 14, 4 Males and 10 Females)
On arrival to the laboratory for participation in the first data collection session (day 1), consenting participants completed a questionnaire to provide information on lower extremity injury history, physical activity, dietary and hydration status, and foam rolling history.15 Anthropometric measures were collected and limb dominance was recorded.15,19 The dominant limb was used to obtain all ROM measures.
Hamstring flexibility was measured indirectly through passive, straight-leg hip flexion ROM with a goniometer (Baseline; Fabrication Enterprises, Inc., White Plains, NY).22 All ROM measures were taken using the following methodology. The surface anatomy of the greater trochanter of the femur and lateral femoral condyle were identified on the skin with a marker to site the landmarks during goniometry measurements. Participants were positioned supine with their non-dominant leg lying flat on the treatment table and secured with straps.15 Examiner one, a certified athletic trainer, obtained hip flexion ROM measures with the goniometer positioned on the lateral side of the thigh. The axis was placed on the greater trochanter, the stationary arm was in line with the torso, and the movement arm was in line with the lateral femoral condyle.23 Examiner two then passively moved the participant into hip flexion, with the knee in extension and the ankle in neutral, until the participant verbalized that a perceived maximum stretch was reached. Passive ROM measurements were chosen because they allowed the researcher to control the motion and ensure that a maximum stretch was achieved. ROM measures were recorded in degrees by examiner one (Figure 1).
Hip flexion range of motion goniometry.
Following ROM measures, participants were familiarized with the foam rolling protocol by watching an instructional video while simultaneously mimicking the foam rolling technique. Four identical foam rollers (TriggerPoint Performance Therapy, Austin, TX) were used. The foam rollers were replaced every 5 business days to limit deformation. A replacement period based on time, as opposed to use, was chosen to maintain blinding of the primary researcher from knowing how often a foam rolling intervention had occurred. Foam rollers were 15 inches in length and 5 inches in diameter, with a non-uniform design made of a polychloride (PVC) pipe core surrounded by high-density foam. The foam roller was aligned with the ischial tuberosity of the experimental leg, participants held themselves up with their hands on the ground behind them, and the foot of the non-rolling leg was flat on the ground with the knee bent.22 Participants were instructed to roll on the experimental leg with as much of their body weight on the foam roller as tolerable without causing pain for the assigned time.
The participants' non-rolling legs assisted in propelling the body along the foam roller.11,15,24 The foot of the experimental leg was relaxed during rolling. Participants rolled the length of the hamstring muscle group in the sagittal plane from the ischial tuberosity to the popliteal fossa.14,15,7,22 A metronome (Owik Time QT-3, Sweet-water, Fort Wayne, IN) was used to maintain a 40-Hz cadence, which was established as a comfortable pace by pilot testing. When the video ended, participants were given unlimited time to practice and review the video until they felt comfortable.
The second data collection session (day 2) was conducted after all participants completed their familiarization session to allow for equal participant grouping and randomization. Participants reported for the second data collection 7 days after the first data collection and within 1 hour of their session one testing time. Participants were reminded of their dietary and hydration in-take from session one and were asked to confirm that they had a similar intake of food, water, and caffeine prior to session two. ROM measures during session two were taken with methods identical to session one. These measurements occurred at the following times: (1) before warm-up; (2) after warm-up; (3) immediately after intervention; and (4) 10 minutes after intervention.
Following before warm-up measures, participants walked at a self-selected pace on a treadmill for a 5-minute warm-up. A 5-minute walking warm-up was chosen due to simplicity and generalizability. ROM measures were obtained immediately after warm-up. After this measure was collected, both examiner one and examiner two removed themselves from the laboratory space to remain blinded to the intervention duration. A third examiner, with knowledge of the participants' group assignments, timed and monitored the interventions.
Participants assigned to one of the two foam rolling intervention groups performed the hamstring foam rolling technique as instructed for their assigned intervention, either 30-second or 2-minute durations. To allow for similar timing for each intervention, the 30-second foam rolling group remained stationary in a long-seated position on the ground for 90 seconds before foam rolling. Participants in the control group were instructed to remain stationary in a long-seated position for 2 minutes to emulate the same body positioning as foam rolling. Examiner three was the only member of the data collection team who had any knowledge of participants' groupings. To eliminate any indication of grouping, the metronome was on during all three interventions. Immediately following completion of foam rolling, perceived pressure exerted on the foam roller was measured using a Numeric Pressure Scale (NPS). The scale was numbered from 0 to 100 and participants were asked by examiner three to record on the scale the perceived percentage of their body weight that was exerted on the foam roller. For example, if participants felt that they exerted 80% of their body weight on the roller, they would write the number 80 on the NPS sheet. The participants in the control group did not report perceived pressure.
Following the assigned intervention, examiners one and two returned to the room for after intervention ROM measures. Then all participants remained stationary on the treatment table with a bolster behind their back and under their knees for 10 minutes. The bolster was placed under the participants' knees for comfort during the long-seated position and to limit a stretch effect by putting the hips and knees into flexion. The 10 minutes of sitting was followed by a ROM measure using identical methods, thus completing the data collection with a total of four ROM measure time points.
The assumptions of normality and homogeneity of variance were tested for the dependent variable ROM prior to data analysis. All tests were non-significant (P >.05), indicating that the assumptions of normality and homogeneity of variance were satisfied. One-way analysis of variance was used to test for group differences at baseline ROM.
A 3 (Group) × 4 (Time) mixed model analysis of variance was performed to test for an interaction between Group (30-second, 2-minute, and control) and Time (before warm-up, after warm-up, immediately after intervention, and 10 minutes after intervention). A paired t test was used to evaluate differences in perceived pressure during foam rolling between foam rolling intervention groups. All statistical tests were performed with IBM SPSS software version 24 (Statistical Package for the Social Science; IBM Corporation, Armonk, NY).
There was no significant difference in ROM measures between groups before exercise (F2,39 = 0.237, P = .790). Participant-reported perceived percent body weight exerted on the foam rollers between the two foam rolling intervention groups was not significantly different (30 seconds: 61.79% ± 21.18%; 2 minutes: 57.86% ± 12.82%, P = .56).
The test for interaction was not significant (F6, 117 = 0.872, P = .518), so the main effects were examined independently. The between-subjects variable “Group” was not significant (F2, 39 = 0.63, P = .939, η2 = 0.003, post hoc power = 0.059). The within-subjects variable “Time” was significant (F3, 117 = 14.366, P < .001). Pairwise comparisons with all groups combined revealed a significant increase in ROM from before warm-up to after warm-up (P = .001) and from after warm-up to immediately after intervention (P = .036). There was no significant change in ROM from immediately after intervention to 10 minutes after intervention (P =.221), although ROM at 10 minutes after intervention was significantly greater than before warm-up ROM (P = .003). Descriptive statistics for ROM measures across time are presented numerically in Table 2 and graphically in Figure 2.
Hamstring ROM (°) at All Time Points (Mean ± SD)
Hip flexion range of motion (ROM) across time (mean ± standard error of the mean). P values reported between given time points and between pre-warm-up and 10 minutes post-warm-up.
The purpose of this study was to examine whether a single foam rolling session of either 30 seconds or 2 minutes had an effect on hamstring flexibility beyond that of a walking warm-up alone. There was no significant difference in ROM among the three intervention groups. These results indicate that, although ROM may increase following foam rolling for 30 seconds or 2 minutes when preceded by a walking warm-up, the foam rolling intervention is not necessarily the cause of the ROM increase. This finding disagrees with our primary hypothesis that foam rolling would increase hamstring flexibility beyond any flexibility gains achieved due to walking alone.
Our results of similar hamstring flexibility measurements between the intervention groups and the control group are supported by previous findings. Foam rolling has been reported to not affect ROM when compared to controls10 and the combination of foam rolling with a dynamic warm-up is no different than a dynamic warm-up alone.16 Although we found no effect of two different treatment durations on ROM, previous studies have reported significant increases in flexibility following foam rolling intervention durations of three sets of 1 minute,15 two sets of 1 minute,13 and ten passes back and forth11 for 2 minutes14,25 and 1 minute.9 However, methodology should be closely considered when interpreting findings. Of these publications, only one11 included a non-foam rolling control group. Junker and Stoggl11 also included a warm-up prior to performing the sit-and-reach ROM measure, but the foam rolling intervention was conducted during a 4-week training period. Taking into account our study's findings and that only one of six previous articles found an increase in flexibility when compared to controls,11 we believe it cannot be definitively concluded that foam rolling increases flexibility when compared to a non-foam rolling control group. Differing foam rolling techniques (eg, sustained pressure on tender or trigger points) could result in ROM gains directly attributed to foam rolling.
We were interested in evaluating the potential extended effects of the warm-up interventions on ROM for a time period similar to the length between warm-up and activity in sport. Ten minutes after intervention has been previously evaluated, with conflicting conclusions on the stability of ROM gains. Some research suggests that foam rolling acutely increases ROM, but intermediate time periods of 10, 15, and 20 minutes diminish these effects.19 In the current study, there were no differences in hamstring ROM measures between the 30-second, 2-minute, and control groups at any of the measured time points, which indicates that the identified therapeutic effects of the warm-up persist for up to 10 minutes. This finding supports our secondary hypothesis, which states that the effects of a warm-up and intervention would remain after a 10-minute time period. However, support for this hypothesis takes on new meaning because the observed ROM gains were attributed to the warm-up and not the foam rolling intervention.
The current study's methodology, evaluating two differing treatment durations compared to controls, was similar to that of Bradbury-Squires et al.,20 who evaluated flexibility measures in three groups: (1) a hand-held roller massager for five sets of 20-second intervention sessions; (2) roller massage for five sets of 60-second intervention sessions; and (3) controls. The authors reported no difference in ROM between the two roller massage groups,20 similar to the current study. This indicates that treatment duration, either during a single session of foam rolling like in the current study or over repetitive sessions,20 does not influence ROM outcomes. However, contrary to the findings of the current study, both hand-held roller massager intervention groups had a significant increase in knee flexion ROM compared to a control group.20
Differences in study outcomes using foam rolling versus a hand-held roller massager have been postulated to be influenced by differences in surface area of force application and percentage of body weight applied in application force.24 It is unknown how much force was applied by each participant during the foam rolling interventions in the current study. However, to optimize force application, we selected a foam roller with a PVC pipe core. Foam rollers with a PVC pipe core exert greater pressure per square inch on the musculature compared to all-foam foam rollers.26 In an attempt to control for pressure magnitude, participants reported the perceived percent body weight exerted on the foam rollers, which was not significantly different between the two foam rolling intervention groups.
Methodology also differs regarding cadence because previous research has used 40,24 50,17 and 13027 Hz. However, a majority of the studies did not standardize cadence with a metronome.9–11,13–16,18–22,25,26 The frequency at which foam rolling is applied to the soft tissue is theorized to affect tissue change.4 If enough stress (or tension) is exerted onto the soft tissue at an optimal rate, strain (or deformation) will occur within the tissue, therefore possibly increasing flexibility.4 Ultimately, more research using similar methodology is needed to truly evaluate the effects that foam rolling prior to activity has on flexibility.
We acknowledge that the current study has limitations, primarily associated with the rigidity of the chosen methodology to control for bias. Passive ROM measures were used to allow greater researcher control. However, active ROM measures may have provided a more functionally relevant measure of hamstring flexibility. Although including healthy individuals with normal ROM may have influenced the ability to find ROM changes following the foam rolling intervention, previous researchers used similar populations and found ROM increases following foam rolling.10,20 The decision to include individuals with normal ROM was based on the clinical practice of individuals with normal ROM frequently using foam rolling in a warm-up routine. Another limitation of the current study is the foam rolling technique that was chosen. The standardized technique of foam rolling with the entire length of the hamstring was chosen for its ease of instruction. Other techniques (eg, rolling perpendicular to the length of the hamstring or incorporating trigger point ischemic compression) could result in different findings. A final limitation is the self-selected walking pace for the warm-up due to the potential differences in walking pace between groups. However, all participants were instructed to “walk at a leisurely pace” because previous research of running warm-ups indicated that speed did not influence ROM measures after warm-up.28
We found no significant differences between two foam rolling treatment durations and controls at any time period (before warm-up, after warm-up, immediately after intervention, and 10 minutes after intervention). Although flexibility increased after foam rolling, it also increased in our control group. Despite being a common treatment modality, the available literature on foam rolling is inconclusive and uses varying intervention parameters. We suspect that anecdotally reported increases in ROM and mobility may be caused by an external sensory input to override the feeling of muscle tightness. This theory is supported by the results of this study, which demonstrated that, under tightly controlled methodology, increases in ROM were a result of the walking warm-up rather than the foam rolling intervention. Because clinical standards continue to develop and be discussed, future research should continue to evaluate the various foam rolling techniques in using foam rolling as an adjunct therapy.
Implications for Clinical Practice
Based on the current study's findings, the treatment goal of foam rolling to increase ROM prior to activity should be reframed. Despite patients in a clinical setting often reporting increased mobility following a foam roller warm-up, the increased ROM observed in the current study was attributed to the walking warm-up alone.
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Patient Demographics (N = 14, 4 Males and 10 Females)
|Condition||Age (y)||Height (cm)||Body Mass (kg)||Day 1 ROM (°)a|
|30-second foam rolling intervention||22.2 ± 2.9||164.8 ± 9.6||69.0 ± 15.0||88.8 ± 16.7|
|2-minute foam rolling intervention||22.9 ± 3.5||164.9 ± 6.7||66.3 ± 19.3||92.6 ± 14.3|
|Control (no foam rolling)||21.4 ± 2.7||167.6 ± 6.2||71.4 ± 11.3||91.3 ± 13.1|
Hamstring ROM (°) at All Time Points (Mean ± SD)
|Condition||30-Second Foam Rolling Intervention||2-Minute Foam Rolling Intervention||Control (No Foam Rolling)||All Groups Combined|
|Before warm-up||89.9 ± 16.8||92.3 ± 12.1||91.7 ± 10.1||91.3 ± 13.1|
|After warm-up||93.9 ± 17.8||94.6 ± 9.2||96.2 ± 11.8||94.9 ± 13.1a|
|Immediately after intervention||96.2 ± 17.9||99.4 ± 11.4||96.7 ± 10.0||97.5 ± 13.2b|
|10 minutes after intervention||95.0 ± 16.9||94.9 ± 11.0||96.1 ± 12.0||95.3 ± 13.2a|