Download A Complete Meta Analysis of Myofascial Release

META ANALYSIS OF MYOFASCIAL RELEASE
A Complete Meta Analysis of Myofascial Release:
Application and Efficacy for Strength Athletes
Mike J. Wines
University of South Carolina
EXSC 499
META ANALYSIS OF MYOFASCIAL RELEASE
Table of Contents
•General Background Information
•Components of Fascia
•Physiological Adaptations to Myofascial Release
•Trigger Points: What Are They and How do They Affect Movement?
•How Does Foam Rolling Differ From Stretching?
•Applications of Myofascial Release
•What Does the Research Say?
•Timing:
•Before, During, or After Weight Lifting?
•Morning or Night?
•Training or Rest Days?
•Potential Negative Consequences of Myofascial Release
•Strength Degradation
•Neural Damage From Extended Periods of Compression
•Perceived Vs. Permanent Changes
•Impact Within Energy System Specific Events: Aerobic Vs. Anaerobic
•Practical Implications
•Summary
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Myofascial release is a recovery and preparatory technique used by many athletes and
weightlifters to improve range of motion and reduce delayed onset muscle soreness (DOMS)
from previous bouts of training. High-density foam rollers are the typical method of application,
but small balls of various densities such as a golf ball, tennis ball, or lacrosse ball can also be
used for a more focal massage. Foam rolling is specifically thought to release soft tissue
adhesions and free immobile fascial sheets. However, in order to properly understand the
mechanisms of myofascial release, one must first examine the components of fascia and
physiology of trigger points.
Thomas Myers, author of Anatomy Trains, refers to fascia as “collagenous-based soft
tissues in the body, and all the cells that create and maintain that network” (2008). Essentially,
the fascial complex that spans throughout our body is “an intricately woven network of
connective tissue that helps maintain structural integrity, provides support and protection, acts as
a shock absorber, assists in hemodynamic and biomechanical processes, provides the matrix for
intercellular communication, creates an environment for post-injury tissue repair, and functions
as the bodies first line of defense against pathogenic agents and infections” (LeMoon, 2008).
Due to the global distribution of fascia, it needs to be treated as a multi-level system and not a
series of parts divided among bodily segments. This fascial system extends throughout the whole
of the body and envelopes every structure except for the digestive, respiratory, and lymphatic
tracts which all have open tubes to allow for movement of nutrients, oxygen, and cellular
byproducts (Myers, 2008). The architect, engineer, and cosmologist Buckminster Fuller invented
a termed known as “tensegrity” which he used to describe geodesic domes and how they were
able to maintain their shape. “Tensegrity” refers to the idea that the integrity or strength of any
structure is dependent upon the tension within each component, hence the name (Myers, 2008).
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Fascia can be thought of in the same way; bones form the basic building blocks for our
anatomical structures but the myofascial network creates the tension within our system that
provides the integrity. However, development of adhesions within this fascial system can lead to
hyper-tonicity of the musculature, restricted movement patterns, and pain even at rest.
The goal of myofascial release is to influence proprioceptors that are responsible for
governing the tension within the fascial network. Muscle contains Golgi tendon organs and
muscle spindles, which influence contraction, force production, and injury prevention, but fascia
contains other receptors that are subject to neural input on a daily basis. Most notably, the
Ruffinian and Pacinian corpuscles are two low-threshold mechanoreceptors, which respond to
very minute levels of tactile stimulation (Purves, Augustine, Fitzpatrick, Katz, LaMantia,
McNamara, & Williams, 2001). These receptors can be thought of as “slow twitch” since they
are mainly responsible for posture and joint positions over an extended period of time (Purves et
al., 2001). When pressure is applied to the skin and muscle tissues beneath, the proprioceptors
are overloaded and shut down, thus decreasing the resting tension of the fibers. So in essence, the
physical length of the tissue itself is not actually changing, but the stiffness of the fibers and the
neural input affecting their facilitation is being altered. Once a trigger point has been discovered,
it can be isolated with a foam roller or lacrosse ball and then the joint should be taken through
the entire range of motion. Another strategy is to use transverse or longitudinal rolling
techniques to try and release the adhesion within multiple planes of movement. After the neural
stimulation to the overactive tissues has been inhibited, the joint must be taken through a full
range of motion with equal force production from all contributing muscles to essentially “rewire”
the nervous system and prevent hyper-tonicity from reoccurring immediately after the adhesion
has been released.
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When skeletal muscle becomes hyper-irritable, the tissue becomes taunt and inhibited due
to the development of trigger points within the fascicle. These adhesions will often lead to pain,
restricted ranges of motion, and muscular dyskinesis. Trigger points are always present in one of
two forms: latent or active. Latent trigger points do not directly present irritation or pain but still
restrict movement and lead to muscular inhibition. Active trigger points on the other hand, are
associated with pain at rest and referred pain patterns. Palpation of either type of trigger point
will typically result in a localized pain response and muscular twitch if adequately stimulated
(Alvarez & Rockwell, 2002). However, the site of pain for active trigger points may be unrelated
to the actual location of the adhesion. For example, pain that radiates down the leg may be due to
development of adhesions in the piriformis muscle from a sedentary lifestyle and prolonged
sitting position. The upper trapezius, scalene, sternocleidomastoid, levator scapulae, and
quadratus lumborum muscles are especially susceptible to adhesions, since these muscles of the
pelvis, neck, and shoulder are mainly responsible for respiration mechanics and maintenance of
our daily postures (Alvarez & Rockwell, 2002). Symptoms can range from tension headaches to
low back pain or even temporomandibular joint dysfunction TMJ and tinnitus (Alvarez &
Rockwell, 2002). Muscular overuse or traumatic injury are both responsible for the development
of trigger points but a study by Bron and Dommerholt (2012) showed that muscular overload
could also be achieved from a variety of factors including: “sustained or repetitive low-level
muscle contractions, eccentric muscle contractions, and maximal or sub-maximal concentric
muscle contractions.” For example, low back pain or tightness are complaint of people
performing various weightlifting activities but this isn’t due to a lack of strength in their spinal
erectors. Instead, it’s actually due to a lack abdominal activation and thus their lumbar spine no
has stability. So, their spinal erectors will contract and pull them into an excessively lordotic
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spinal position as a “protective mechanism” to allow the body to garner some type of stability
and prevent unwarranted movement of the lumbar vertebrae.
At a physiological level, the trigger point hypothesis proposes that unwarranted
intramuscular tension is due to concentrated sarcomere shortening from an excessive release of
acetylcholine within the synaptic cleft (Bron & Dommerholt, 2012). During sustained
contractions, a muscle will switch to anaerobic metabolism in order to synthesize ATP with the
help of oxygen and glucose. However, during anaerobic glycolysis, the pyruvic acid that is
generated will be converted to lactic acid and remain trapped within the muscle fiber due to the
capillary restriction that is present during sustained low-level contractions. This localized
ischemia will lead to a decrease in intramuscular pH and trigger the release of multiple
inflammatory mediators within muscle cell (Bron & Dommerholt, 2012). This constant state of
intramuscular tension and obstructed capillary blood flow prevents additional oxygen from
entering the muscle fiber and therefore disrupts ATP re-synthesis. Without the presence of ATP,
myosin and actin cross bridges will not detach due to the local energy crisis from a lack of
oxygen (Bron & Dommerholt, 2012). These tetanic sarcomeres will not only cause pain, but also
prevent complete muscular lengthening and limit range of motion within a joint. This becomes
extremely important during weightlifting, when maximal voluntary contraction of specific
musculature is required in order to prevent injury or maintain spinal neutrality to reduce shearing
forces upon the intervertebral discs. For example, Stewart McGill (1989) found that during a
60lb squat, the sacroiliac joint (SI) must withstand over 1,461 pounds of force during the
movement. In order to combat this combination of compression, shear, and moment forces, the
musculature of the pelvis must contract to create joint and stabilization forces. This stability
allows for successful load transfer between the torso and lower limbs and protects the joint from
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the torque and compressive forces being generated (Barker, Hapuarachchi, Ross, Sambaiew,
Ranger, & Briggs, 2013). However, individuals with trigger points present in the gluteus
minimus, medius, or maximus muscles will lack the ability to achieve complete gluteal
activation and thus the SI joint will be compromised during movements involving axial loading
patterns. A study by Eichenseer, Sybert, and Cotton (2011) demonstrated that between 13% and
30% of low back pain was the result of SI joint dysfunction due to muscular inhibition, joint
laxity, or hypermobility. Another study by Alvarez and Rockwell (2002) reported that up to 23
million people, roughly 10% of the US population, have one or more chronic disorders of the
musculoskeletal system. Myofascial release as a technique has been important for
musculoskeletal well being and decreased pain. However, it may also prove beneficial for
cardiovascular health in sedentary subjects, as recent studies have shown that it is able to reduce
arterial stiffness, improve arterial function, and improve vascular endothelial function (Okamoto,
Masuhara, and Ikuta, 2013).
Stretching has typically been the pre and post-workout modality advocated for many
years, but now research has shown that lengthy static stretching may account for acute reductions
in force production potential and increased risk of injury (Fowles, Sale, & MacDougall, 2000).
Due to the viscoelastic properties of muscle, passive stretching has been shown to elicit a shortterm change in muscle extensibility and an increase in joint range of motion. The elastic
capabilities of muscle are determined by a variety of non-contractile, cytoskeleton components,
most notably, titin (De Deyne, 2002). However this biomechanical model is not the only
mechanism that affects muscle length and elasticity, there are also neurological and molecular
factors at work during a passive stretch. For example, when using proprioceptive neuromuscular
feedback as a stretching mechanism, the Golgi tendon organ and muscle spindle afferent
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receptors are altered which modifies the activity of specific alpha-motoneurons and input from
the central nervous system (De Deyne, 2002). It has also been proposed that at a molecular level,
there is a chain of specific reactions between intrafusal components that results in a cascade of
cellular signaling which will eventually lead to increased sarcomere length and number, also
known as myofibrillogenesis (De Deyne, 2002). Due to these slight biomechanical, neurological,
and molecular changes, myofascial release and static stretching should both be implemented in
order to achieve the full benefits within the muscle fiber. Myofascial release also attempts to
influence neural input along with the elastic and tensile properties of muscle, but instead of
mainly focusing on the length of the muscle fiber itself, it seeks to release the fascial tension that
has been built up due to adhesions. However, unlike static stretching, research has shown that
foam rolling does not decrease the rate of force production and a simple 2-minute bout of
myofascial release improved flexibility by 12.7% (11 degrees) and ten minutes later, flexibility
was still 10.3% greater than normal (9 degrees) (MacDonald, Penney, Mullaley, & Drake, 2013).
Myofascial release can actually be applied through a number of different methods, which
will influence the muscle fiber in unique ways. Foam rollers and lacrosse balls are used as a
means of self-massage but trigger points can also be addressed with acupuncture, dry-needling,
deep tissue massage, cryo/thermotherapy, ethyl chloride spray, ultrasonography, transcutaneous
electrical nerve stimulation, or local injections with saline, anesthetic, or steroid (Alvarez &
Rockwell, 2002). However, many of these applications are more invasive and require
professional assistance and expensive equipment. With just a simple lacrosse ball and a foam
roller, most patients will find that they can release the vast majority of their trigger points with
some simple self-massage at home. Not only is this inexpensive, but for those with a fear of
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needles, it allows them immediate pain relief without having to suffer though the anxiety of
assisted treatment from a health care provider.
Given the research surrounding the efficacy of myofascial release and its importance for
strength athletes, the main question becomes, when is the optimal time for application? Should it
be implemented pre-workout as a preparatory technique to enhance range of motion, reduce pain,
and offset the effects of a sedentary lifestyle? Or, should one concentrate their efforts on the
post-workout time period, once they have completed multiple repetitions through a specific
movement pattern and their muscles have remained in a contracted state for a substantial length
of time? A recent study by Healey, Hatfield, Blanpied, Dorfman, and Riebe, (2013) compared
the effects of pre-activity myofascial release to a control group to determine if timing could
enhance sports performance. After recording isometric smith machine squat strength, counter
movement jump height, and agility in the 5-10-5 yard shuttle run, the researchers concluded that
athletic performance was neither enhanced nor reduced when using myofascial release before a
training bout. It is important to note however, that the researchers observed less fatigue within
the foam-rolling group when compared to the control group. These results are supported in
another study by MacDonald, Button, Drinkwater, and Behm (2013) who demonstrated that
myofascial release is effective when used post-workout to restore joint range of motion and
reduce the intensity of delayed onset muscle syndrome. Implementing myofascial release before
a workout, it has been shown to increase flexibility with no detrimental affects to force or torque
production through maximal voluntary isometric contractions (Sullivan, Silvery, Button, &
Behm, 2013). Several authors have stated that myofascial release could be dangerous due to the
potential impingement and damage to nerve endings from compressive forces coupled with highdensity rollers and balls. However, a key point to remember is that myofascial release isn’t a
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completely passive and static technique. Once the trigger point is found, apply compression and
then actively take the joint through a complete range of motion to release the adhesion. One
should be able to distinguish between trigger points and nerve endings by the sensation that is
felt as they roll over them. Nerve endings will result in a burning or numbing feeling but trigger
points are only painful initially but the discomfort dissipates as you work through the range of
motion and continue to actively massage the adhesion.
Myofascial release clearly has a beneficial effect for athletes that participate in highintensity, anaerobic activities but what about those who prefer more aerobic, steady state
exercise? Okamoto, Masuhara, and Ikuta, (2013) stated that foam rolling can improve arterial
and vascular endothelial function and decrease arterial stiffness, which could certainly provide
additional physiological benefits for aerobic athletes. Less arterial stiffness coupled with
improved vascular function could potentially enhance blood pressure regulation, circulation, and
oxygen delivery. This would greatly enhance aerobic performance by prolonging time to fatigue
and improving recovery due to an increase in the delivery of nutrient rich blood to working
muscles. Also, another important point to consider is the duration and mechanics of aerobic
activities. Most aerobic sports are repetitive and rhythmic in nature but also require the same
movement pattern to be completed for hundreds, if not thousands of repetitions. However, many
endurance athletes don’t perform any sort of weight lifting or cross training, so they may present
compensatory patterns that will influence osteo and arthrokinematics. For example, many
runners present with pain in the iliotibial (IT) bands due to faults in stride mechanics once
fatigued. As they begin to get tired, pronation occurs and this leads to tibial internal rotation and
hip adduction and internal rotation within the kinetic chain. At the same time, this places a
stretch upon the hip abductors, which feeds into a vicious cycle of increased length and tension
META ANALYSIS OF MYOFASCIAL RELEASE
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to the IT band. However, since the IT band inserts at the superior, lateral aspect of the patella
and crosses the SI joint and lumbar spine as it ties into the thoracolumbar fascia, it will also
affect patellar tracking, hip mobility, and spinal mechanics (Barker, Hapuarachchi, Ross,
Sambaiew, Ranger, & Briggs, 2013). MacDonald, Penney, Mullaley, and Drake study (2013),
found that a quick 2-minute session of myofascial release of the quads improve range of motion
within the knee by up to 11 degrees. This affected stride length, Q-angle at the hip, and patellar
tracking within the patellofemoral groove. Therefore, myofascial release that is applied on rest
days and after bouts of training will be of extreme importance for aerobic athletes, to help
maintain proper joint mobility and ensure that compensations don’t result in chronic injuries.
Foam rolling may be ineffective at increasing flexibility permanently (Miller & Rockey,
2006) but due to the vast body of conclusive research on its efficacy, it is wise for athletes to
implement it both pre and post-workout. It should primarily be used as a preparatory technique
for 10 to 15 minutes pre-workout and then 5-10 minutes post-workout as well. For those who
cannot engage in myofascial release post-workout due to limited time constraints, it would be
beneficial to include more soft tissue work in the evening before bed to enhance parasympathetic
tone and promote recovery and relaxation from the day’s training session. Also, for those who
spend lengthy amounts of time in a seated position, it would be wise to implement various breaks
throughout the day in which myofascial release is included to promote circulation, improve range
of motion, and help reduce the deleterious effects on the spine and pelvis. For athletes training
with a high frequency, it may also be valuable to include myofascial release on rest days along
with other relaxation and recovery implements, such as saunas, contrast therapy, and ice baths.
Research is still a bit inconclusive on permanent flexibility changes from myofascial release
(Miller & Rockey, 2006); therefore, it would most beneficial to execute this technique at the start
META ANALYSIS OF MYOFASCIAL RELEASE
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of every workout to improve joint range of motion without any negative side effects to
neuromuscular input and force production during high velocity muscular contractions.
In conclusion, myofascial release has benefits for both anaerobic and aerobic athletes.
Increased perfusion and range of motion without subsequent decreases in performance can all be
attributed to the removal of trigger points within the musculoskeletal system. Myofascial release
can be beneficial for both athletes and non-athletes by increasing range of motion and perfusion
to muscle groups. A high-density foam roller can quickly and easily release adhesions and free
fascial sheets. Further research into this area will provide athletes with the data needed to
understand and implement the most effective and productive application of myofascial release to
enhance workouts and recovery.
META ANALYSIS OF MYOFASCIAL RELEASE
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