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Short-Duration Massage at the Hamstrings Musculotendinous Junction Induces Greater Range of Motion

Huang, Stacey Y1; Di Santo, Mario2; Wadden, Katie P1; Cappa, Dario F3; Alkanani, Thamir1; Behm, David G1

The Journal of Strength & Conditioning Research: July 2010 - Volume 24 - Issue 7 - p 1917-1924
doi: 10.1519/JSC.0b013e3181e06e0c
Original Research

Huang, SY, Di Santo, M, Wadden, KP, Cappa, DF, Alkanani, T, and Behm, DG. Short duration massage at the hamstrings musculotendinous junction induces greater range of motion. J Strength Cond Res 24(7): 1917-1924, 2010-Massage for the purpose of health dates back to early civilization and more recently has been used in the management and prevention of sport injuries. Massage has also been used as part of a warm-up to help increase acute flexibility. However, the physiological benefits and mechanisms of massage are not well known. The purpose of the present study was to investigate the effectiveness of 3 massage conditions on hip flexion range of motion (ROM). This experimentation involved a novel massage technique, which focused the massage on the musculotendinous junction for a short duration. Ten recreationally active women ranging from 21 to 36 years in age participated in this study. Participants were subjected to 3 massage conditions (no massage, 10-second massage, and 30-second massage) in a random order on separate days. Hip flexion angle, passive leg tension, and electromyography (EMG) were measured thrice before and within 10 seconds after the intervention. A main effect for conditions was found with the 30-second massage providing a 7.2% increase in hip flexion ROM that was significantly greater than the control condition (p < 0.05). Significant interactions occurred with an increased ROM (p < 0.05) from pre to posttests of 5.9 and 7.2% for the 10- and 30-second massage conditions, respectively. There were no significant differences in passive tension or EMG for any conditions or time. With a significant increase in hip angle and no associated increase in passive tension or EMG, there is a suggestion that 10 and 30 seconds of musculotendinous massage induces greater ROM through a modified stretch perception, increased stretch tolerance, or increased compliance of the hamstrings. Musculotendinous massage may be used as an alternative or a complement to static stretching for increasing ROM.

1The School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John's, Canada; 2Institute for the Teaching of Physical Education, Cordoba, Argentina; and 3Faculty of Health Science, University of Catamarca, Catamarca, Argentina

Address correspondence to Dr. David G. Behm, dbehm@mun.ca.

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Introduction

Among medical, health, and athletic professionals, flexibility and aerobic conditioning and strength training are considered important components of an exercise program (1,23). Van den Tillaar (40) indicated that insufficient range of motion (ROM) caused by poor muscle flexibility may be a cause of muscle strain and increased risk of injury. To enhance ROM from a health perspective, it is typically necessary to engage in systematic stretching over a period of time (40).

In many sports such as squash, tennis, wrestling, and goaltending in ice hockey among others, it is necessary to achieve a greater ROM to ensure athletic success. The recent literature has many examples of static stretching increasing ROM (4-7,9); however, it has also been reported to impair subsequent force (6,16,27,33), jump height (10,39,44,45), sprint time (14,15,34), muscle activation (6,36,37), reaction, and movement time and balance (4). Compared with common static stretching techniques, at least 1 study using massage has been shown to increase ROM without exhibiting detrimental effects on force production (31). In addition, 15 and 30 minutes of massage, respectively, did not adversely affect 30-m sprint running time (20). Barlow et al. (2) reported no effect of 15 minutes of hamstring massage on the electromyographic (EMG) activity associated with a submaximal voluntary contraction. Other than a single study using 15 minutes of petrissage massage that impaired muscle strength (43), the few studies documenting the effects of massage on athletic performance generally indicate minimal adverse effects. Hence, if massage can increase ROM, it may be an alternative or complement to static stretching during the warm-up, cooldown, and specialized flexibility training sessions.

However, not all massage studies report increased ROM. Two studies using 15 minutes of hamstrings massage indicated no change in ROM with adolescent soccer players (26) and active adults (2). Conversely Hopper et al. in 2 studies observed increased hamstrings flexibility with 8 minutes of dynamic soft tissue mobilization (24,25) and classical massage (25). Therefore, the effectiveness of traditional massage for increasing ROM is still debatable.

The present study introduces a novel massage technique to increase ROM. Previous massage studies applied massage on the muscle belly (2,24-26,31), whereas the present study focused massage on the musculotendinous junction. Secondly, the previously cited research regarding massage effects on ROM has implemented 6-30 minutes of massage, whereas the massage duration in the present study was 10 and 30 seconds. This duration would be more conducive to the time limitations of most warm-ups and cooldowns. Flexibility enhancing protocols that save time without compromising ROM, could be advantageous to a variety of athletes and the general population that often lists time constraints as a limitation to exercise and fitness.

Athletes that are seeking to achieve a greater ROM or individuals who have difficulty achieving a functional ROM with traditional static stretching could benefit from a short duration, simple technique that can be used in conjunction with static stretching or alone to enhance ROM. Musculotendinous massage before static stretching has been used successfully in clinical settings (personal correspondence; Professor Di Santo; Argentina) with both athletic and clinical populations. However, there have been no control groups with which to validate these clinical findings. Also, there are no studies attempting to identify possible mechanisms underlying their action.

Although contentious, massaging the musculotendinous junction could theoretically activate the inhibitory action of the Golgi tendon organ (GTO) (12) or lead to a presynaptic inhibition of the Ia sensory fibers from the spindles of the activated muscle (8). Hence, this study will examine both EMG activity and passive muscle tension to examine if it is possible to detect if massage-induced changes in ROM are because of changes in reflex-induced muscle activation or muscle stiffness or compliance.

The objective of this study was to investigate the effects of short duration (10 and 30-second) musculotendinous massage on hip flexion ROM, passive hamstrings tension, and EMG activity. It is hypothesized that with a short-duration massage, concentrated on the musculotendinous junction of the hamstrings, there will be an increase in ROM with no associated increase in passive leg tension or EMG activity.

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Methods

Experimental Approach to the Problem

To validate techniques to improve ROM presently being used by professionals in the field, 2 different durations of musculotendinous friction massage were compared to a control group to ascertain if claims of clinical success were valid or could be ascribed to a placebo effect. The research design was a classical experimental design with 1 control and 2 experimental conditions. Subjects attended 3 sessions on separate days (control, 10-, and 30-second massage) within a 1-week period. Counterbalancing was used with the order of the intervention techniques to reduce practice or boredom effects (13). Each session consisted of a 5-minute active aerobic cycle warm-up followed by a 5-minute rest period. After the post-warm-up rest period, 3 pretest measures of hip flexion ROM, hamstrings EMG, and passive muscle tension were performed. After another 5-minute rest period, 1 of the 3 intervention techniques was applied (control, 10, and 30 seconds of musculotendinous friction massage). Three posttest measures (same as pretest) were taken starting at 5-10 seconds after the intervention. Hip flexion ROM, hamstrings passive tension, and EMG were the variables recorded and analyzed during the 3 pre and posttest measures. The 3 postmeasures were separated by 5 seconds of rest, during which the leg was returned to rest on the table. The mean of the 3 pretest and posttest measures was used for analysis (Figure 1).

Figure 1

Figure 1

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Subjects

The participants were 10 women ranging in age from 21 to 36 years with a mean age of 24.3 ± 5.9 years. The participants had mean weights and heights of 73.3 ± 12.5 kg and 172.3 ± 4.3 cm, respectively. All participants were healthy and recreationally active. None of the participants were on a consistent training program. They were all former high-school or university level former athletes who presently participated in a variety of recreational activities (aerobic fitness on treadmills, rowing and cycle ergometers, basketball, volleyball) at least twice a week. Because testing was performed in January and February, most extracurricular activities were indoors. None of the participants had injuries that limited ROM at the hip or knee joint.

Participants were recruited through convenience (visit undergraduate courses and ask for volunteers) and snowball sampling (participants contacting other individuals that they thought would be interested in the study). Because only a few men volunteered for the study, women were selected to reduce the possibility of high variability associated with gender differences in ROM and muscle tension. There was and insufficient number of male volunteers to parcel gender as a separate variable. All participants provided written consent to participate in this study. The study was approved by the Memorial University of Newfoundland Human Investigation Committee.

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Measurement Protocols

Hip Flexion Range of Motion

Static flexibility is defined as the ROM that is available to a joint or series of joints (18). Hip flexion ROM in this study was measured directly using a manual goniometer and the passive straight leg raise technique (22). The goniometer was accurate to 1°. This technique involved placing the subject in a supine position and attaching a custom plastic knee brace to ensure the knee remained in full extension. The subject's leg was passively raised to induce flexion at the hip with minimal hip rotation until the subject verbally indicated the point of discomfort had been reached. The point of discomfort was described to the participants as the point at which they first felt the onset of uncomfortable tension or stretch in the hamstrings. During the leg raise, no movement of the opposite leg was ensured. The participant was also instructed to remain relaxed and to avoid any voluntary contractions. The angle measured was the angle between the long axis of the thigh and the long axis of the torso, using the greater trochanter as the axis of rotation. Range of motion data were calculated by subtracting posttest values from pretest values for each condition. Three trials were performed with the mean used for analysis.

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Hamstrings Electromyography Activity

Electromyography activity was monitored in an effort to ascertain whether the interventions provoked reflex modulated changes in muscle EMG activity. Unlike a strong muscular contraction, the EMG activity from a passive stretch was expected to provide a low signal-to-noise ratio. Thus, a pretest was used for all interventions in addition to the control condition in an attempt to decrease the variability that might appear when EMG activity is recorded and compared from separate days (sessions). Surface EMG recording electrodes (Ag/AgCl, disc shape, 10 mm in diameter) were placed on the hamstrings (semimembranosis) at the midpoint between the ischial tuberosity and the posterior aspect of the lateral epicondyle of the femur. Skin preparations included shaving the area of interest, followed by removal of dead epithelial cells with a piece of sandpaper, and cleansing with isopropyl rubbing alcohol (70%). Three electrodes (Kendall; Medi-Trace 130; electrocardiography conductive adhesive electrodes) were used to determine EMG output. Two electrodes were placed back to back (∼2-cm electrode to electrode distance) over the marked midpoints on the posterior aspect of the thigh. A ground electrode was placed on the proximal head of the fibula. Electromyography activity was sampled at 2,000 Hz, with a Blackman −61 dB bandpass filter between 10- and 500-Hz, amplified (bipolar differential amplifier, input impedance = 2 MΩ, common mode rejection ratio ≥ 110 dB minutes (50/60 Hz), gain × 1,000, noise > 5 μV), and analog-to-digitally converted (12 bit) (Biopac Systems Inc. [Holliston, MA, USA] DA 100 and analog to digital [A/D] converter MP100WSW; Hilliston, MA, USA) and stored on a personal computer for further analysis. The filtered signals were rectified and integrated over a 3-second (between the 1- and 4-second mark of the 5-second stretch) period during maximum ROM (AcqKnowledge III, Biopac Systems Inc.).

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Hamstrings Passive Tension

Passive tension of the muscle is described as the tension provided by the tendons and muscle membranes when the muscles are not activated (21). Changes in passive muscle tension associated with massage would illustrate if alterations to the mechanical properties (e.g., compliance) of the musculotendinous unit had occurred with the interventions. The passive tension of the hamstrings was indirectly measured using the passive torque force created at the posterior of the knee at the point of discomfort. The passive torque force was measured using a handheld dynamometer (Lafayette Manual Muscle Test System Model 01163). The handheld dynamometer operates at a range of 0-22.6 kg and is accurate to ±1% over the full scale. Its resolution is 0.1 kg. The device was placed in the popliteal space perpendicular to the long axis of the leg with the knee fully extended and held for 5 seconds. The maximum force (kg) was measured and recorded. Three trials were performed with the mean value used for analysis.

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Pilot Muscle Tension Validity Study

To ensure the handheld dynamometer (manual strain gauge) was sensitive to changes in tension associated with increases in ROM, the subjects participated in a prior pilot stretch study with no massage intervention. Subjects' extended leg (same preparation as previously described) was passively placed in a flexed hip position while the individual lay supine on a mat. Muscle tension (force) measures were taken using the same aforementioned protocol except that the leg was placed in 5 positions (angles). The 5 extended leg positions were randomly allocated consisting of (a) 10° from perpendicular to the floor (80° from floor or 100° from the torso) and labeled as 100°, (b) 15° from perpendicular to the floor and labeled as 105° (from the torso), (c) 110°, (d) 115°, (d) 120° (from the torso), or 60° from perpendicular to the floor. The stretched position was held for 5 seconds, and a 1-minute rest was allocated between measures. Identical to the aforementioned description of passive muscle tension, the device was placed in the popliteal space perpendicular to the long axis of the leg and held for 5 seconds. The maximum force (kg) was measured and recorded. Three trials were performed with the mean value used for analysis.

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Intervention Protocol

Each subject completed the 3 protocols within a 1-week period. Because all women were on birth control, radical fluctuations in the hormonal responses affecting flexibility would not have been expected. A 5- minute active warm-up was followed by a 5-minute rest period. Subsequent to the 5-minute post-warm-up rest period, 3 pretest measures were performed followed by another 5-minute rest period. Interventions included the control protocol that involved no massage where the subject remained in the supine position for 30 seconds. Postintervention measures commenced 5-10 seconds after each intervention or control condition. For the 10- and 30-second massage conditions, friction massage was applied at the musculotendinous junction of the distal portion of the hamstrings. Friction massage is characterized as an accurately delivered penetrating pressure applied through the fingertips (41). This pressure was applied in small circular motions with deep pressure by the same investigator for each subject. The subject's knee was extended, and the subject was in a supine position. The investigator grasped the subject's thigh with both hands (thumbs on the quadriceps) and applied friction pressure in circular motions with the fingers at a pace of approximately 1 rpm to the musculotendinous junction of the hamstrings. This duration and type of massage have been reported to be successfully used in certain clinical applications (personal correspondence with Professor Di Santo). However, without control conditions, the claims of clinical success might be attributed to a placebo effect.

The first of 3 hip flexion ROM measurements was conducted immediately (within 5-10 seconds) after the massage technique. With 5 seconds between the ROM measurements, 5 seconds to place the leg at its greatest ROM and 5 seconds for ROM, tension, and EMG measures for the entire testing protocol was completed within 1 minute after the massage treatment.

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Statistical Analyses

Data were analyzed using SPSS version 16.0. Descriptive statistics (means ± SD) were used to summarize the data. Kolomogorov-Smirnov normality tests were applied to all the data to ensure normality, and Mauchly's test was conducted to determine sphericity of the data. With no violations of normality or sphericity, no adjustments were made. Change in hip flexion ROM, passive tension, and EMG were assessed separately using a 2-way (3 × 2) repeated-measures analysis of variance (ANOVA) with the factors being massage conditions (control, 10-, and 30-second massage) and time (pre and posttest). The pilot muscle tension validity study employed repeated-measures 1-way ANOVA to compare the 5 positions (angles). A post hoc pairwise comparison with no adjustments was used to compare between group differences. A level of significance was set at p ≤ 0.05 (13).

Reliability was analyzed by comparing the pretest measures of the 3 interventions (pretest of control, 10-, and 30-second massage) with an intraclass correlation coefficient (ICC) with a 95% confidence interval (SPSS version 16.0).

When comparing the change in ROM for the 10- and 30-second massage to the control conditions, the statistical power at an alpha level of 0.05 was calculated to be 64.3 and 95.3%, respectively. The statistical power for the EMG data at an alpha level of 0.05 was 97.1, 57.6, and 56.4% for the pre and posttesting of the control, 10- and 30-second massage data, respectively.

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Results

The data for change in hip flexion ROM, passive tension, and EMG activity did not show significant skewness or kurtosis for any condition. A Kolomogorov-Smirnov normality test was conducted indicating that the data were normal for all conditions and measures. Mauchly's test was conducted on the data, and sphericity was not violated (13). The ICC test for reliability revealed correlation coefficients of 0.95 for ROM, 0.66 for EMG activity, and 0.74 for passive muscle tension.

There were no significant changes in passive tension or EMG activity across conditions or time.

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Pilot Muscle Tension Validity Protocol

With no massage intervention, the pilot tension study exhibited significantly (p = 0.008) greater muscle tension at the greatest ROM (100°) as compared to 115° and 120° positions (Figure 3). The 100° position demonstrated 20.1 and 21.3% greater passive muscle tension than the 115° and 120° positions, respectively.

Figure 3

Figure 3

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Range of Motion

There was a main effect for conditions (pre and posttest measures combined) with the 30-second massage providing a significantly greater hip angle ROM than the control condition (p < 0.05; ES = 0.73). There was no significant difference between the other conditions (Figure 2). There was also a main effect for time (3 conditions combined) with the postmassage hip angle being 7.0% significantly greater (premassage: 81.8 ± 17.3° vs. postmassage: 87.6 ± 17°) than the premassage hip angle (p < 0.01; ES = 0.716).

Figure 2

Figure 2

Significant interactions occurred with no prepost changes in ROM in the control group contrasting with an increased ROM (p < 0.05) in the posttests of 5.8 and 11.3% for the 10-second (ES= 2.3) and 30-second (ES = 2.3) massage conditions, respectively (Figure 4).

Figure 4

Figure 4

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Discussion

The most important finding of the current study was the significant increases in hip flexion ROM with only 10 seconds (5.9%) and 30 seconds (7.2%) of musculotendinous massage. Previous studies have reported conflicting results with a single bout of 15 minutes of massage eliciting no significant changes in ROM with adolescent soccer players (26) and active adults (2) contrasting with 3 other studies reporting increased hamstrings flexibility with 8 minutes (24,25) and 3 minutes of massage (31). This main finding of the present study indicates that a brief duration massage at the musculotendinous junction can provide an increase in hamstrings flexibility (hip flexion ROM) that is comparable to other common methods of stretch, albeit with a shorter time commitment.

These findings are comparable or exceed the effects of acute bouts of static stretching. Various static stretching studies have shown increased hamstrings flexibility of 10.2% with 30 seconds (46), 6% with 270 seconds (36), 3.6%, with 90 seconds (35), and approximately 2% with 45 seconds (3) of static stretching. Similar to some proprioceptive neuromuscular facilitation (PNF) stretching studies that have demonstrated 7.8% increases in hip ROM after 5 minutes of PNF stretching (17), the present massage results also exceed the 0.3% increase in leg extensor ROM with 4 different PNF exercises reported by Marek et al. (30). Hence, short-duration massage at the musculotendinous junction without additional stretching can provide ROM improvements similar to other stretching techniques. Although the massage technique was delivered without additional stretching, further studies should examine whether the combination of stretching and massage provides cumulative increases in ROM. This combination of musculotendinous massage followed immediately with static stretching has been used by certain clinicians (e.g., Professor Di Santo) to augment the ROM achieved with static stretching alone in both athletic and clinical populations. Now that this study has verified with a control condition the effectiveness of musculotendinous junction massage for increasing ROM, further studies using control groups can determine both the cumulative effects of massage and static stretching and the persistence (duration) of the technique.

The significant increase in hip flexion ROM in the present study did not elicit increases in passive leg tension. The pilot muscle tension validity study demonstrated that without any interventions, hamstring passive tension increased 21.3% over a 20° hip flexion ROM. Thus, the lack of increase in hamstring passive tension with a massage-induced ∼6-7% increase in ROM could suggest an increased muscle compliance or decreased muscle stiffness because of the massage intervention. Increases in muscle-tendon compliance may be achieved with massage by mobilizing and elongating shortened or adhered connective tissue (41). Another possibility is that the massage caused increases in skin and muscle temperatures leading to augmented blood flow to the area (41). Although Drust et al. (11) reported increased skin and muscle temperatures with massage, their massage duration was a minimum of 5 minutes compared with a maximum of 30 seconds in the present study. Thus, it would seem more likely that the focused massage upon the musculotendinous junction resulted in a mechanically induced decrease in muscle-tendon stiffness.

Electromyography activity did not increase with the increased ROM in the present study. It has been suggested by some authors that massaging the muscle would produce an autogenic inhibition of the target muscle by activating the GTO (12) or lead to a presynaptic inhibition of the Ia sensory fibers from the spindles of the activated muscle (8). Taking into consideration that an increased ROM should place the muscle spindles under greater stress (because an elongated or stretched muscle), an increase in EMG activity because of spindle-induced stretch reflexes might be expected. However Chalmers (8) elucidates that the amount of reflex-induced EMG activity associated with a maximum ROM is very low or minimal and may not be physiologically meaningful. Similarly, Magnusson et al. (29) observed a stretch-induced EMG signal equal to only 1% of the MVC EMG. Because in their study, the EMG activity did not change in conjunction with force loss after 90 seconds of stretch, they also concluded that the EMG associated with the stretch reflex did not contribute significantly to the stretch-induced force resistance. In the present study, 8 of 10 subjects experienced a decrease in EMG activity after the 30-second massage condition (↓ 12.1%); however, the variability of the data obviated any statistical significance. If there are neurophysiological inhibitory responses present similar to the stretch-induced depression of the Hoffman (H)-reflex (19,38), the signal-to-noise ratio of the global (surface) EMG signal may not be sensitive enough to illustrate these massage-induced effects.

A further possibility has been suggested that massage may increase ROM by reducing the muscle's ability to detect pain and therefore allowing a greater ROM before experiencing discomfort (41). This theory refers to local lateral inhibition in the spinal cord. The inhibition may be caused by tactile information stimulating larger rapidly conducting nerve fibers that could compete with and partially block smaller, slower nerve fiber that detect pain (41). One study by Mitchell et al. (32) found that after PNF, subjects' stretch tolerance was greater than after a slow stretch. These findings are similar to those of Magnusson et al. (28) who also reported that increased flexibility may be attributed to altered stretch perception or increased stretch tolerance.

Given these results, musculotendinous junction massage may also be a viable alternative in rehabilitation situations to help restore ROM. Patients with extremely limited ROM or those who experience excessive pain during passive or PNF stretching may benefit from musculotendinous junction massage to regain flexibility. Massage may also benefit rehabilitation patients through psychophysiological mechanisms such as lower anxiety (47) and increased relaxation (42).

A limitation to this study was that only 1 bout of massage was used, and only 1 postintervention measure was taken. Therefore, the duration of the musculotendinous massage effect was not determined. Secondly the massage technique was used in isolation and not in conjunction with other stretching activities to determine if there was an additive effect of musculotendinous massage to other stretching techniques. It would also be interesting to investigate the effectiveness of this massage technique when used in a long-term stretching program.

In conclusion, the present study demonstrated that using 1 bout of a short-duration (10- or 30-second) massage at the musculotendinous junction can result in increased ROM without an increase in passive muscle tension or EMG activity. It was also demonstrated that 30 seconds of musculotendinous massage provided greater overall ROM benefits than 10 seconds. This increased ROM might be attributed to a massage-induced decrease in muscle-tendon stiffness. A neurophysiological mechanism might involve a modified stretch perception or increased stretch tolerance because competing afferent signals. Further research is needed to identify the mechanisms of musculotendinous massage, but it appears that it may be a useful technique for increasing acute ROM for athletes, the general fitness or health-concerned individuals and rehabilitation patients.

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Practical Applications

Athletes, coaches, and fitness enthusiasts can apply massage at the musculotendinous junction for at least 10 seconds and expect a significant increase in static ROM. Thirty seconds of musculotendinous massage should provide an even greater improvement in flexibility. Clinicians tend to use the musculotendinous massage before static stretching to attain greater ROM. Individuals such as athletes who wish to maximize their flexibility may consider adding this short-duration massage technique to their stretching routine to augment increases in ROM. The research tends to indicate a lack of impairment in subsequent performance with massage. Thus, short-duration musculotendinous massage may be beneficial in increasing ROM before or after a training routine or athletic event without adding an additional substantial time involvement.

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Acknowledgments

This study was supported in part by a research grant from the Natural Science and Engineering Research Council of Canada.

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Keywords:

stretch; flexibility; autogenic inhibition; manual manipulation; passive tension

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