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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 37-41

Effect of foam rolling of quadriceps, hamstring, and IT band on knee passive range of motion and physical function in patients with patellofemoral pain syndrome - Randomized controlled trial


S.S. Agrawal Institute of Physiotherapy, Navsari, Gujarat, India

Date of Submission25-Nov-2020
Date of Decision10-Feb-2022
Date of Acceptance19-Feb-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Dr. Shlesha Maulik Vaidya
S.S. Agrawal Institute of Physiotherapy, Navsari - 396 445, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_305_20

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  Abstract 

Background and Aim: There are several techniques for limited and painful knee flexion, but there are very few evidences about the effect of foam rolling in patients with patellofemoral pain syndrome (PFPS). A Randomized control study was designed to determine the effect of foam rolling as well as of stretching on knee passive range of motion (ROM) and functional status in patients with patellofemoral pain and to compare the effect with that of static stretching. Materials and Methods: Thirty patients diagnosed with chronic knee pain were randomized into two groups (experimental and controlled groups) with 15 subjects in each group. The experimental group received foam rolling exercises on quadriceps, hamstring, and IT band muscles. Passive stretching of all the abovementioned muscles was given to the controlled group. The intervention was given for 3 alternate days per week for 4 weeks per patient. Strengthening exercises were given to both the groups. Outcome measures were passive ROM and knee injury and osteoarthritis outcome score scale. Results: Within-group analysis (P < 0.05) showed that both the interventions had a significant effect on passive range of motion and physical function in patients with PFPS. However, intergroup analysis (P > 0.05) showed that there is no significant difference between the two groups in terms of outcome measure. Conclusion: Both foam rolling and conventional treatment (stretching) are effective in improving knee ROM and functional status in patients with PFPS. However, the myofascial release (foam rolling) treatment showed slightly better (however, not significant) clinical improvement in terms of improving knee ROM and functional status in patients with PFPS.

Keywords: Knee pain, KOOS scale, myofascial release


How to cite this article:
Vaidya SM. Effect of foam rolling of quadriceps, hamstring, and IT band on knee passive range of motion and physical function in patients with patellofemoral pain syndrome - Randomized controlled trial. Arch Med Health Sci 2022;10:37-41

How to cite this URL:
Vaidya SM. Effect of foam rolling of quadriceps, hamstring, and IT band on knee passive range of motion and physical function in patients with patellofemoral pain syndrome - Randomized controlled trial. Arch Med Health Sci [serial online] 2022 [cited 2022 Oct 6];10:37-41. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/37/347967


  Introduction Top


A common cause of knee joint pain in young adults is where the patella (knee cap) and cartilage in the joint is affected by imbalance in the muscles surrounding the knee.[1] The medical term that describes this is patellofemoral pain syndrome (PFPS) and also referred to as runner's knee or a “tracking” problem. Decreased flexibility of tensor fasciae latae, hamstrings, quadriceps or gastrocnemius, and soleus muscles is also seen. In the patients with patellofemoral pain, weakness, inhibition, or altered recruitment or timing of firing of vastus medialis oblique muscle occurs. There is irritation of IT band as it passes over the lateral femoral condyle and attaches to the patella and lateral retinaculum that may cause anterior pain. The pathologies that lead to anterior knee pain have been classified under the name of PFPS. PFPS is the most prevalent orthopedic condition seen in sports medicine and is a common presenting complaint in adolescents and young adults.[2] PFPS is also the primary diagnosis in about 25% of all running injuries.[3] Treatment for PFPS is especially promising for the short term, but long-term results are much less successful.[4] The total incidence for PFPS ranges from 8.75% to 17%; however, the incidence among females is much greater at 12.7% compared to 1.1% of males.[5] Young females who regularly participate in running and jumping activities may be particularly at risk. In a clinical analysis of 40 women with PFPS, pain was associated with increased activity.

Foam rolling is a simple self-manual therapy technique often used to improve flexibility, recovery, and athletic performance. Although much more research is needed to clarify the effects of foam rolling, recent investigations have indicated that it is an effective method for improving flexibility, subjective markers of recovery, and athletic performance. Foam rolling is used by an abundance of fitness enthusiasts. These techniques are often referred to as self-myofascial release therapy.[6]

Stretching is used to describe any therapeutic maneuver designed to increase the extensibility of soft tissues, thereby improving flexibility by elongating structures that have adaptively shortened and have become hypomobile over time.

Stretching intervention is an integral component of an individual rehabilitation program. It is an important element of fitness and conditioning programs designed to promote wellness and reduce the risk of injury and re-injury.

Less evidence exists to show the effect of foam rolling in patellofemoral syndrome. Hence, this study was undertaken to prove the efficacy of foam rolling in patellofemoral syndrome.


  Materials and Methods Top


The study design was a double-blind randomized controlled trial. Thirty participants reporting to the physiotherapy outpatient department in a hospital who were 18–45 years of age and had diagnosis of patellofemoral pain syndrome were included. Inclusion criteria included retropatellar or peripatellar pain. Inclusion criteria included retropatellar or peripatellar pain when walking stairs, squatting, running, cycling, sitting with flexed knee for a prolonged period of time and grinding of the patella along with a positive Clarke's test. Exclusion criteria included knee osteoarthritis, previous knee injury, patellar tendinopathy, Osgood–Schlatter's disease, and other defined pathological conditions of knee. Patients with degenerative conditions, patients older than 45 years, patients who have undergone hip, knee, ankle surgery, and postoperative knee-fracture cases were excluded.

Primary outcome measures were knee ROM and physical function. Prior to participation, informed written consent was taken from each participant. Ethical clearance was obtained from the institutional ethical committee. The subjects were randomly divided into two groups, i.e., experimental group (foam rolling plus strengthening exercises of knee) and control group (stretching plus strengthening exercise of knee) by computer-generated random number table. One investigator managed the assignment scheme and provided the assignment to the treating physiotherapists in a series of consecutively numbered opaque envelopes. Allocation was concealed from the outcome assessor and participants at all times and from the physiotherapist until the point of treatment. Both the groups received the selected treatment for 3 sessions in a week for 4 weeks [Figure 1].
Figure 1: CONSORT 2010 Flow Diagram

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Control group (conventional group)

Passive stretching of quadriceps muscle

The patient is asked to lie on his belly (prone position) with both the legs extended. The therapist, standing on the side of the couch, moves the patients' lower leg gently toward the buttocks and holds the stretch for 30 s and repeats 3 times.[7]

Passive stretching of hamstring muscle

The patient is asked to lie on the back (supine position) with both the legs extended. The therapist is positioned on the side nearer to the feet and then the therapist raises the affected leg toward the ceiling by placing the patient's heel upon the therapist's shoulder to elevate the leg and the other hand should be placed above the knee to stabilize the joint and the pelvis should not be raised. Hold it for 30 s and repeat it for 3 times.

Passive stretching of IT band

The patient is asked to lie down in supine position. The patient is asked to put the affected foot beside the opposite knee. The therapist then pushes the bent knee toward the opposite side and holds the stretch for 30 s. Repeat it for three times.

Experimental group

This group received the foam rolling treatment in which the patients were asked to foam roll their respective muscles' location, i.e., hamstring, quads, and IT band muscles.

  • To foam roll the hamstring muscle, the foam roller is placed underneath the hamstring belly and the patient is asked to raise the buttocks up from the plinth and is asked to perform long sweeping movements, stopping just short above the back of the knee. The other leg should be placed outside and down. Repeat it for three to four times
  • To foam roll the quadriceps muscle, the patient is asked to be in prone on elbow/hand position and the foam roller is placed under the affected thigh, i.e., quadriceps, and is asked to start rolling sweeping motions up and down the quadriceps. It should not interfere with the joint line. Repeat it for three to four times
  • To foam roll the IT band, the patient is asked to come on one side and place the foam roller just below the hip and stack both of the legs over the plinth, using one or both the hands for support. Shift the weight side to side so that through the roller rolls down the side of thigh toward the knee and rolls it back the other way. The patient is asked to not go past the knee and hip joint. Furthermore, you could place the top leg out in front and perform the rolls. Rolling done for 60 s and repeated thrice.


Statistical analysis

Outcomes were analyzed using an intention to treat analysis. Comparisons of the PROM and KOOS outcome measures across the assessment points were analyzed using Wilcoxon signed-rank test and Mann–Whitney U-test. All the participants completed 12 treatment sessions. The following [Table 1] and [Table 2] represents data with respect to PROM and KOOS score of the control and experimental groups. Descriptive statistics including P value, standard deviation, and mean were calculated. Comparison within the groups was assessed using Wilcoxon signed-rank test. Comparison between the groups was assessed using Mann–Whitney U-test. All statistical analyses were performed with SPSS version 19.0 (IBM Corporation, New York, USA). The significance level was set up at <0.05. At each of the following consultations, no patient reported either exacerbation of pain or inflammation following foam rolling therapy. There were no complications arising from the foam rolling intervention. All patients completed each treatment session (no dropouts).
Table 1: Experimental group of 15 subjects with patellofemoral pain syndrome (within-group comparison)

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Table 2: Control group of 15 subjects with patellofemoral pain syndrome (within-group comparison)

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  Results Top


Significant time effects (P < 0.001) were detected. The KOOS scores were significantly lower than baseline overall assessment points in each task (P < 0.001). The mean change in score for the experimental group was 13.27 ± 11.266. The greatest change occurred immediately after the first treatment and pain was minimal at the final assessment in the intervention group [Table 1]. The control group failed to show statistically significant improvement in KOOS scores (P > 0.001). The mean change in KOOS score for control group was 7.40 ± 7.45 [Table 2]. There was a significant improvement from baseline in knee flexion range of motion (ROM) immediately after the initial treatment and the final assessment point for both the groups. The mean change in range for the experimental group was 3.60 ± 1.724 and for the control group was 4.53 ± 4.068. There was no significant difference between groups in terms of both outcome measures [Table 3]. This means that foam rolling did not prove better than static stretching when both the interventions were compared.
Table 3: Between-group comparison for Knee Injury and Osteoarthritis Outcome Score and knee read-only memory

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  Discussion Top


The present randomized controlled trial was conducted to study the effect of foam rolling and stretching treatment in patients with knee pain, primarily PFPS. This study includes 12 interventions with foam rolling in the experimental group and that of conventional therapy (stretching) in the control group. Individually, both the groups showed improvement, but when they were compared, there was no significant difference between the two groups. These exercise interventions have specific exercises (stretching and myofascial release exercises)[8] to help maintain joint ROM and reduce the tightness of the muscles as well as pain. In order to achieve these goals, it is important to ensure that the exercises are performed with the good technique. Hence, the conservative physiotherapy treatment in patients with patellofemoral knee pain is to improve functional ability and reduce pain. Results of the present case are similar to a study done by Andrew R Mohr et al. on the effect of foam rolling and static stretching on restricted passive hip flexion ROM.[9] The outcome showed that there is a change in passive hip flexion ROM from the preintervention measure on day 1 to the postintervention measure on day 6. Subjects receiving foam roll combined with static stretch had a greater change in passive hip flexion ROM compared with the static stretch, foam rolling, and control groups.[9] A study by HsuanSu et al. compared the acute effects of foam rolling and static stretching on quadriceps and hamstring muscles. Therefore, they concluded that foam rolling is more effective than static and dynamic stretching in acutely increasing flexibility of the quadriceps and hamstrings without hampering muscle strength, and may be recommended as part of a warm-up in healthy young adults.[10] John Cronin et al. studied the acute effects of hamstring stretching and vibration on dynamic knee joint ROM and jump performance on ten male participants who participated voluntarily. Thereby, they concluded that a single bout of stretching produced a small, short-lived change in dynamic knee joint ROM but did not change jump performance. The addition of vibration alone or in combination with stretching did not influence dynamic knee joint ROM or jump performance. One of the important reasons for improvement in functional status with foam rolling treatment in the patients with knee pain, primarily with PFPS, is that it did cause reduction in pain, tightness in the muscles of hamstring, quadriceps, and IT band. Thus, the pain-free range of movement allows the subjects to perform exercises and activities of daily life more successfully.[11]

Further, previous studies have only looked at the effects of foam rolling over tissue that contains both muscle and its surrounding fascia.[11] This study has included the effects of foam rolling over the ITB, a tissue composed primarily of connective tissue, devoid of any significant contractile component.[12] There are three theories proposed to explain observed changes in ROM after foam rolling. Most prevalent is that myofascial adhesions develop over time, resulting in reduced ROM. Advocates of foam rolling propose that it is able to reduce fascial adhesions,[12] thus improving ROM. Second, alterations in blood flow and vascularization within the fascia are shown to change as a result of foam rolling, which may lead to reduced neural inhibition.[11] Finally, there is a proposed neurological mechanism that involves the facilitation of muscle relaxation/inhibition, which would occur to a greater degree in myofascial tissue than fascia alone.[11]

Myofascial adhesions

Fascia is made of connective tissue, mostly collagen and elastin. It does have Pacinian corpuscles and Ruffini nerve endings, suggesting that it may play a role in proprioception. It also has free nerve endings and chemoreceptors, suggesting that it can be a source of pain.[13] Histologically, fascia is composed primarily of fibroblasts, which maintain the extracellular matrix. There is some speculation that sustained static positions cause a stiffening or thickening of the colloidal gel which results in a restriction of ROM and altered lines of pull on muscle action and restricted motion, termed “fascial adhesions.”[14] The results of the current study suggest that if any fascial adhesions existed in the sample pool, foam rolling over myofascial tissue would improve ROM.

Alterations in vascularity

There is some evidence that foam rolling can improve blood supply to an area by improving the elasticity of the arteries. Foam rolling can possibly act to relieve vascular adhesions formed and relieve pain and hence inhibition.[15]

Neural plastic changes

Recent evidence suggests that the changes in ROM observed as a result of foam rolling are due to neural excitability and improved facilitation of muscle tissue. Golgi tendon organs are located in connective tissue. Golgi tendon organs respond to slow stretch – which is simulated by foam rolling – by reducing their firing rate, thus reducing tonus in adjacent muscle.[16] This “softening” may account for a perceived increase in joint ROM. Effects on Ruffini corpuscles have been suggested as a cause for the changes due to foam rolling.[17] These slow-adapting receptors could alter their neural transduction with a sustained stretching stimulus. With reduced transmission to the brain, there is less for the brain to perceive, resulting in less efferent activity to target muscles, and therefore an overall improved neural effect on tissue ROM. This in turn could result in improved neuromuscular activity.[18]

Limitations to the study and future considerations

Although the present study was a randomized controlled trial, some methodical limitations were still present. The study consisted of a few subjects which should be revised to a large number of subjects. Further, no follow-up was taken. There is a need to investigate the long-term effect of specific techniques of foam rolling technique, so as to find out how long the effects last for, whether its effect is maintained or reduced on a long-term basis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Silman A. A new paradigm for musculoskeletal clinical trials in the UK: The Arthritis Research Campaign (ARC) Clinical Studies Groups initiative. Rheumatology (Oxford) 2008;47:777-9.  Back to cited text no. 1
    
2.
Vora M, Curry E, Chipman A, Matzkin E, Li X. Patellofemoral pain syndrome in female athletes: A review of diagnoses, etiology and treatment options. Orthop Rev (Pavia) 2017;9:7281.  Back to cited text no. 2
    
3.
Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician 2007;75:194-202.  Back to cited text no. 3
    
4.
Capin JJ, Snyder-Mackler L. The current management of patients with patellofemoral pain from the physical therapist's perspective. Ann Jt 2018;3:40.  Back to cited text no. 4
    
5.
Mullaney MJ, Fukunaga T. Current concepts and treatment of patellofemoral compressive issues. Int J Sports Phys Ther 2016;11:891-902.  Back to cited text no. 5
    
6.
Hall M, Chadwick Smith J. The effects of an acute bout of foam rolling on hip range of motion on different tissues. Int J Sports Phys Ther 2018;13:652-60.  Back to cited text no. 6
    
7.
Bandy WD, Irion JM, Briggler M. The effect of time and frequency of Static Stretching on flexibility of the Hamstring muscles. Phys Ther 1997;77:1090-6.  Back to cited text no. 7
    
8.
Škarabot J, Beardsley C, Štirn I. Comparing the effects of self-myofascial release with static stretching on ankle range-of-motion in adolescent athletes. Int J Sports Phys Ther 2015;10:203-12.  Back to cited text no. 8
    
9.
Mohr AR, Long BC, Goad CL. Effect of foam rolling and static stretching on passive hip-flexion range of motion. J Sport Rehabil 2014;23:296-9.  Back to cited text no. 9
    
10.
Su H, Chang NJ, Wu WL, Guo LY, Chu IH. Acute effects of foam rolling, static stretching, and dynamic stretching during warm-ups on muscular flexibility and strength in young adults. J Sport Rehabil 2017;26:469-77.  Back to cited text no. 10
    
11.
Cronin J, Nash M, Whatman C. The acute effects of hamstring stretching and vibration on dynamic knee joint range of motion and jump performance. Phys Ther Sport 2008;9:89-96.  Back to cited text no. 11
    
12.
Bushell J, Dawson S, Webster M. Clinical relevance of foam rolling on hip extension angle in a functional lunge position. J Strength Cond Res 2015;29:2397-403.  Back to cited text no. 12
    
13.
Beardsley C, Škarabot J. Effects of self-myofascial release: A systematic review. J Bodyw Mov Ther 2015;19:747-58.  Back to cited text no. 13
    
14.
Mense S. Innervation of the thoracolumbar fascia. Eur J Transl Myol 2019;29:8297.  Back to cited text no. 14
    
15.
Stecco C, Gagey O, Belloni A, Pozzuoli A, Porzionato A, Macchi V, et al. Anatomy of the deep fascia of the upper limb. Second part: Study of innervation. Morphologie 2007;91:38-43.  Back to cited text no. 15
    
16.
Wiewelhove T, Döweling A, Schneider C, Hottenrott L, Meyer T, Kellmann M, et al. A meta-analysis of the effects of foam rolling on performance and recovery. Front Physiol 2019;10:376.  Back to cited text no. 16
    
17.
Hindle KB, Whitcomb TJ, Briggs WO, Hong J. Proprioceptive Neuromuscular Facilitation (PNF): Its mechanisms and effects on range of motion and muscular function. J Hum Kinet 2012;31:105-13.  Back to cited text no. 17
    
18.
Proske U. What is the role of muscle receptors in proprioception? Muscle Nerve 2005;31:780-7.  Back to cited text no. 18
    


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