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189
Athletic Training & Sports Health Care | Vol. 6 No. 4 2014
Effectiveness of Myofascial Release Therapies on
Physical Performance Measurements
A Systematic Review
Timothy C. Mauntel, MA, ATC, CES, PES; Michael A. Clark, DPT, MS, CES, PES; and Darin A. Padua, PhD, ATC
ABSTRACT
The muscular and skeletal systems work interdependently to pro-
vide effi cient movement. Effi cient movement can be inhibited by
fascial restrictions and myofascial trigger points (MTrP). Myofascial
release therapies target fascial restrictions and MTrPs to increase
range of motion (ROM) and muscle function prior to rehabilitation
or physical activity. A systematic review was needed to examine
the eff ectiveness of these therapies so that clinicians and athletes
may use only the most effi cacious methods. A search of PubMed,
SPORTDiscus, CINAHL, and Cochrane Library electronic databases
was completed to identify articles; 10 articles were included. All
but 2 studies observed a signifi cant increase in ROM, whereas no
study observed a signifi cant change in muscle function following
treatment. Therefore, clinicians should use myofascial release ther-
apies prior to rehabilitation or physical activity, as they eff ectively
increase ROM without decreasing muscular function, resulting in
increased movement effi ciency and decreased injury risk. [Athletic
Training & Sports Health Care. 2014;6(4):189-196.]
The musculoskeletal system is an intricate net-
work of interconnecting and independent tis-
sues that must work together effectively to pro-
vide efficient movement. When muscles and fascia are
subjected to microtrauma, fascial restrictions may form
and inhibit normal muscular function.1-3 Myofascial
trigger points (MTrP) may develop independently or in
conjunction with fascial restrictions, resulting in inhibi-
tion of normal muscular function.4
Intra- and extramuscular fascia may become restric-
tive and create deficits in muscular function. These defi-
cits manifest as decreased joint range of motion (ROM),
altered neuromuscular properties, and decreased
strength.1-3 In addition, fascia may contract as part of
an evolutionary adaptation that prepares the body for
activity, as well as to attempt to protect the body from
repetitive stresses by providing increased stability to the
musculoskeletal system.2 These adaptations can increase
perimysium thickness, resulting in greater decreases in
ROM.3 Myofascial trigger points may form in conjunc-
tion with fascial restrictions or may form independently.
Myofascial trigger points are hyperirritable areas within
taut bands of skeletal muscle or fascia that can further
decrease ROM and inhibit the strength of the affected
muscle.4 Myofascial trigger points are subdivided into
active and latent categories; active MTrPs cause pain and
irritation during rest and activity, whereas latent MTrPs
generate pain only when palpated and during activity.4
Collectively, myofascial restrictions and MTrPs can
contribute to dysfunctional movement patterns1-4 that
can increase an individual’s injury risk.
A number of soft tissue manual therapies have been
developed to address fascial restrictions and MTrPs to re-
store normal ROM and muscular function. These manual
therapies are commonly used by sports medicine clini-
cians, strength and conditioning professionals, and athletes
prior to rehabilitation and physical activity to improve
movement efficiency through increased ROM and muscu-
lar function. Improved movement efficiency results in de-
creased injury risks.5 Common noninvasive therapies used
by clinicians, strength and conditioning professionals, and
Mr Mauntel and Dr Padua are from the Department of Exercise and Sport Science,
Sports Medicine Research Laboratory, University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina; and Dr Clark is from Fusionetics, Atlanta, Georgia.
Received: September 5, 2013
Accepted: April 23, 2014
Posted Online: July 17, 2014
The authors have disclosed no potential confl icts of interest, fi nancial or
otherwise.
Address correspondence to Timothy C. Mauntel, MA, ATC, CES, PES,
Department of Exercise and Sport Science, Sports Medicine Research Laboratory,
University of North Carolina at Chapel Hill, 032 Fetzer Hall, CB #8700, Chapel Hill,
NC 27599; e-mail: tmauntel@gmail.com.
doi:10.3928/19425864-20140717-02
190 Copyright © SLACK Incorporated
Mauntel et al
athletes include positional release therapy (PRT),6 active re-
lease technique (ART),7,8 trigger point pressure release,9-12
and self-myofascial release.13-15 Positional release therapy
is a manual therapy that places the muscle in a shortened
position to promote muscle relaxation.16,17 Positional re-
lease therapy has evolved from a strain–counterstrain
technique, where the clinician applies light pressure to the
MTrP throughout the treatment.18,19 Active release tech-
nique is used to treat areas of tension or adhesions found
in muscles or surrounding soft tissues. The muscle is taken
from a shortened position to a lengthened position while
the clinician maintains contact with the problematic area to
keep constant tension on the fibers of that tissue.7 Trigger
point pressure release, formerly referred to as “ischemic
compression,” involves applying a downward pressure
on an MTrP. The downward pressure locally lengthens
sarcomeres20 and creates a flushing of cellular metabolic
by-products commonly associated with MTrPs, which
can assist in reestablishing normal metabolic functions of
the involved tissues.21 Self-myofascial release involves the
individual applying pressure to an MTrP or area of fascial
restrictions with the use of a specialized device, such as a
foam roller13 or a hand-held rolling device.14,15
Myofascial release therapies are not limited to the
previously described manual therapies. Additional
therapeutic modalities found to be efficacious in re-
ducing signs and symptoms associated with myofascial
restrictions and MTrPs include therapeutic ultrasound
with10 and without medication,11 therapeutic low-level
laser treatment,10 thermotherapies,22 electrical stimula-
tion,22 and dry needling.23 However, these modalities
can be costly, time consuming, and physically invasive.
Because of the limitations of these modalities, they
are not readily available to all sports medicine clini-
cians, strength and condition professionals, or athletes.
Therefore, the focus of the current review is on non-
invasive manual therapies that involve physical contact
between the clinician or a specialized device and the
athlete, as these therapies can be easily learned and ef-
ficiently applied to and by the athletes themselves.
A systematic review was needed to examine the ef-
fectiveness of each of the previously described non-
invasive manual therapies for reducing the effects
of myofascial restrictions and MTrPs. Such a review
would provide sports medicine clinicians and strength
and conditioning professionals with vital informa-
tion to improve clinical practice and the health of the
athletes they serve. Although many of the aforemen-
tioned manual therapies decrease pain associated with
myofascial restrictions and MTrPs,10-12 this review will
examine the effectiveness of each of the manual thera-
pies for increasing ROM, muscular activation, and
muscular force production. These clinical measures
may be of the greatest importance to sports medicine
clinicians, strength and conditioning professionals,
and athletes alike, as not all myofascial restrictions and
MTrPs result in active pain,4,12 and some of the dis-
cussed therapies are used prophylactically prior to the
onset of pain.13-15 More importantly, improvements
in ROM and muscular function can lead to improved
movement efficiency and reduced injury risk.5
LITERATURE REVIEW
Search Strategy
An electronic literature search of the PubMed,
SPORTDiscus, CINAHL, and Cochrane Library
databases was completed through June 2013 by one au-
thor (T.C.M.). Keywords related to fascial restrictions,
MTrPs, and myofascial release therapies were included,
and these keywords were searched individually and in
multiple combinations. Table 1 shows a list of the search
terms, combinations, and search-term modifiers that
were used. A manual search of the reference list of each
selected article was also completed by the same author
to identify articles not returned in the original search.
Study Inclusion and Exclusion Criteria
Articles were included if they fulfilled the following cri-
teria: (1) written in English; (2) focused on the treatment
of fascial restrictions or MTrPs through the use of thera-
pies involving mechanical pressure; (3) ROM, electromy-
ography, muscular activation, or muscular force results
were reported pre- and posttreatment; and (4) effect
size was able to be calculated through data available in
the article or through correspondence with the respec-
tive author. Articles that reported effects on pain or self-
perceived function only or utilized modalities that used
energies other than mechanical pressure were excluded
from the review. Systematic reviews and meta-analyses
were also excluded, as the authors wanted to develop
their own interpretations of the available data.
Study Selection
One author (T.C.M.) ensured that all selected stud-
ies met the minimum requirements for inclusion. The
author then conferred with another author (D.A.P.) to
confirm inclusion and appropriateness of each article.
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Athletic Training & Sports Health Care | Vol. 6 No. 4 2014
Myofascial Release Therapies
Data Abstraction
One author (T.C.M.) abstracted information from the
selected articles. The abstracted information included
study population, treatment utilized, duration of the
treatment, length of time until follow-up measure-
ments, and measured outcomes.
Data Synthesis
Effect Size Calculation. The effect size for each treat-
ment was calculated as it pertained to ROM, muscular
activation, or muscular force. Effect sizes were calculated
from the means, standard deviations, and sample sizes
provided through the articles or through personal cor-
respondence with the articles’ authors. Effect sizes ⬎0.70
were rated strong, 0.41 to 0.70 were moderate, and ⬍0.40
were weak.24 This allowed for comparison between treat-
ments and the various measured outcomes.
Methodological Quality Assessment. The authors
used the PEDro scale25 to assess the methodological
quality of all studies included in the current review. The
PEDro scale evaluates for 11 criterion to determine the
methodological quality of a study. PEDro scores range
from 0 = poor to 10 = high. The article by Maher et al25
reports additional information about PEDro scoring.
The authors recognize that the PEDro scale is intended
to be used solely for randomized control trials; how-
ever, we were unaware of any standardized assessment
of the quality of crossover or quasi-experimental stud-
ies. Two authors (T.C.M., D.A.P.) independently scored
each study included in the current review and then con-
ferred with one another, discussed any disparities in the
scores, and reached a consensus on each item included in
the PEDro scale. Following data abstraction and meth-
odological quality assessments, all authors compiled the
findings of the included studies to form a comprehen-
sive synthesization and interpretation of the data.
RESULTS
Search Results
The initial search of the electronic databases resulted in
873 articles available for review. Duplicate articles were re-
moved, and 497 titles and abstracts were reviewed. Review
of the 497 titles and abstracts resulted in 477 articles being
removed. Six additional articles were excluded following
full-text review. The reference list of each remaining article
was reviewed, and an additional 3 articles were identified.
The inability to abstract the necessary data from certain ar-
TABLE 1
Comprehensive List of Electronic
Database Search Terms
SEARCH TERM
Self-myofascial release
Foam rolling
Self-massage
Myofascial trigger point release
Self-myofascial release + EMG
Self-massage + range of motion
Ischemic compression + EMG + NOT cardiac + NOT myocardial
Ischemic compression + range of motion + NOT cardiac + NOT
myocardial
Ischemic release + EMG + NOT cardiac + NOT myocardial
Ischemic release + range of motion + NOT cardiac + NOT myocardial
Passive release therapy + EMG passive release therapy + range of motion
Active release technique + EMG
Active release technique + range of motion
Abbreviation: EMG, electromyography.
Figure. Flow chart of systematic literature search results and data abstraction.
192 Copyright © SLACK Incorporated
Mauntel et al
ticles or through correspondence with the articles’ authors
resulted in 4 articles being removed. In total, 10 articles
were included in the current review. The Figure depicts a
flow chart of the article search results and data abstraction.
Characteristics of Included Studies
One article focused on PRT,6 2 focused on ART,7,8 4 fo-
cused on a variation of trigger point pressure release,9-11,26
and 3 focused on some form of self-myofascial re-
lease.13-15 Nine articles reported pre- and posttreatment
ROM measurements or posttreatment measurements
between the treatment and control groups.6,7,9-11,13-15,26
Three articles reported pre- and posttreatment muscu-
lar activation measurements,8,13,15 and 3 articles reported
muscular force production measurements.8,13,15 Table 2
presents an overview of the included studies.
Range of Motion. Nine articles examined the effects
of the previously mentioned therapies on ROM; 4 fo-
cused on hamstring flexibility,6,7,14,15 1 focused on quad-
riceps flexibility,13 1 focused on triceps surae flexibility,9
and 3 focused on cervical neck flexibility.10,11,26 All but
2 studies observed a statistically significant increase in
ROM for at least 1 ROM measurement following treat-
ment. Table 3 shows all ROM results.
Muscular Activation. Three articles examined the ef-
fects of the mentioned therapies on muscular activation
levels; 2 focused on the quadriceps8,13 and 1 focused on
the hamstrings.15 No study reported statistically signifi-
cant differences between pre- and posttreatment mea-
surements for any variable measuring muscular activa-
tion. Table 4 presents muscular activation results.
Muscular Force Production. Three articles examined
the effects of the mentioned therapies on muscular force
production; 2 focused on the quadriceps8,13 and 1 focused
on the hamstrings.15 No study reported statistically signifi-
cant differences between pre- and posttreatment measure-
ments for any measure of force or rate of force develop-
ment. Table 5 shows the muscular force activation results.
Methodological Quality
Assessment of methodological quality was based on the
calculated PEDro scores. Standard interpretation of the
scores was used to determine the methodological quality
of the included studies.27 The methodological quality was
TABLE 2
Systematic Literature Review Overview
TREATMENT
STUDY (YEAR)
STUDY
DESIGN
STUDY
PARTICIPANTS
(AGE [Y])
TARGETED
MUSCLE
INCLUSION
CRITERIA TYPE DURATION
NO.
SESSION
Birmingham et al6
(2004)
Cross-over 33 M/F (18+) Hamstrings Lacking ⭓10° knee
extension
PRT 90 sec 1
Drover et al8 (2004) Quasi-
experimental
9 M/F (18+) Quadriceps,
patellar tendon
Anterior knee pain ART Not reported 1
George et al7 (2006) Quasi-
experimental
20 M (21 to 30) Hamstrings Physically active ART 4 passes 1
Grieve et al9 (2011) RCT 20 M/F (18+) Triceps surae ⭐10° dorsifl exion MTrP release 3 min 1
Kannan10 (2012) RCT 45 M/F (20 to 40) Upper
trapezius
MTrPs IC + static
stretching
5 min 5
MacDonald et al13
(2013 )
Quasi-
experimental
11 M (18+) Quadriceps Resistance trained Foam rolling 2 x 1 min 4
Mikesky et al14 (2002) Cross-over 30 M/F (18+) Lower
extremity
NCAA Div II athlete SMR 2 min 1
Oliveira-Campelo et al26
(2013)
RCT 117 M/F (18+) Upper
trapezius
MTrPs IC 90 sec 1
Sarrafzadeh et al11
(2012)
RCT 60 F (18+) Upper
trapezius
MTrPs MTrP release 90 sec 6
Sullivan et al15 (2013) Cross-over 17 M/F (18+) Hamstrings Physically active SMR 1 x 5 sec,
2 x 10 sec
1
Abbreviations: ART, active release technique; F, female; IC, ischemic compression; M, male; MTrP, myofascial trigger point release; NCAA Div, National Collegiate Athletic Association Division,
PRT, positional release therapy; RCT, randomized control trials; SMR, self-myofascial release.
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Athletic Training & Sports Health Care | Vol. 6 No. 4 2014
Myofascial Release Therapies
deemed to be high (6 to 10) for 6 studies6,9,10,14,15,26 and fair
(4 to 5) for 4 studies.7,8,11,13
DISCUSSION
The current systematic review provides a comprehen-
sive review of noninvasive myofascial release thera-
pies and their effects on ROM, muscular activation,
and muscular force production. Evidence supports the
use of myofascial release therapies to improve ROM
following both single and multiple sessions of treat-
ment.7,9-11,13,15,26 The evidence also suggests that myofas-
cial release therapies do not inhibit or improve muscu-
lar performance.8,13,15 These conclusions are based on a
limited number of studies of fair to high methodological
quality. The findings of the current review are impor-
tant because myofascial release therapies continue to
gain popularity in the rehabilitation and sports perfor-
mance environments.
TABLE 3
Systematic Literature Review Range of Motion Results
PRETREATMENT POSTTREATMENT
STUDY (YEAR) MEASUREMENT MEAN SD MEAN SD EFFECT SIZE
Birmingham et al6 (2004) Right popliteal angle 156.1 3.7 156.6 3.3 0.14
Birmingham et al6(2004) Left popliteal angle 155.9 3.7 156.9 3.3 0.14
George et al7 (2006) Sit-and-reacha35.5 7.6 43.8 7.1 1.13
Grieve et al9 (2011) Dorsifl exion ROMa4.60 3.8 7.9 5.7 0.68
Kannan10 (2012) Cervical contralateral fl exiona1.20 1.1 2.2 1.4 0.78
MacDonald et al13 (2013) Knee fl exion ROM, 2 mina77.6 10.2 88.2 8.5 1.13
MacDonald et al13 (2013) Knee fl exion ROM, 10 mina77.6 10.2 86.4 8.9 0.92
Mikesky et al14 (2002) Hip fl exion (hamstrings) 92.0 2.0 93.0 2.0 0.50
Oliveira-Campleo et al26 (2013) Cervical fl exion, 10 min 55.6 10.9 59.5 9.6 0.38
Oliveira-Campleo et al26 (2013) Cervical fl exion, 24 hrs 55.6 10.9 59.1 10.1 0.33
Oliveira-Campleo et al26 (2013) Cervical fl exion, 1 wk 55.6 10.9 58.6 10.3 0.28
Oliveira-Campleo et al26 (2013) Cervical extension, 10 min 64.7 12.2 68.6 11.0 0.34
Oliveira-Campleo et al26 (2013) Cervical extension, 24 hrs 64.7 12.2 66.9 10.8 0.19
Oliveira-Campleo et al26 (2013) Cervical extension, 1 wk 64.7 12.2 66.7 10.7 0.17
Oliveira-Campleo et al26 (2013) Cervical ipsilateral fl exion, 10 min 46.1 4.6 47.4 5.4 0.26
Oliveira-Campleo et al26 (2013) Cervical ipsilateral fl exion, 24 hrs 46.1 4.6 46.2 4.5 0.02
Oliveira-Campleo et al26 (2013) Cervical ipsilateral fl exion, 1 wk 46.1 4.6 45.7 4.0 0.09
Oliveira-Campleo et al26 (2013) Cervical contralateral fl exion, 10 mina39.8 5.1 46.0 5.8 1.14
Oliveira-Campleo et al26 (2013) Cervical contralateral fl exion, 24 hrsa39.8 5.1 46.6 5.4 1.29
Oliveira-Campleo et al26 (2013) Cervical contralateral fl exion, 1 wka39.8 5.1 46.8 5.4 1.33
Oliveira-Campleo et al26 (2013) Cervical ipsilateral rotation, 10 mina71.2 5.7 76.3 4.5 0.99
Oliveira-Campleo et al26 (2013) Cervical ipsilateral rotation, 24 hrsa71.2 5.7 77.2 4.0 1.22
Oliveira-Campleo et al26 (2013) Cervical ipsilateral rotation, 1 wka71.2 5.7 76.5 6.7 0.85
Oliveira-Campleo et al26 (2013) Cervical contralateral rotation, 10 min 77.3 4.3 78.4 3.7 0.27
Oliveira-Campleo et al26 (2013) Cervical contralateral rotation, 24 hrs 77.3 4.3 78.8 3.6 0.38
Oliveira-Campleo et al26 (2013) Cervical contralateral rotation, 1 wk 77.3 4.3 79.3 4.3 0.47
Sarrafzadeh et al11 (2012) Cervical lateral fl exiona37.1 4.2 42.1 4.3 1.18
Sullivan et al15 (2013) Sit-and-reach, 1 ⫻ 5 sec 31.2 8.2 32.2 8.3 0.13
Sullivan et al15 (2013) Sit-and-reach, 1 ⫻ 10 sec 31.3 8.6 32.9 8.8 0.21
Sullivan et al15 (2013) Sit-and-reach, 2 ⫻ 5 sec 31.1 9.1 32.0 9.1 0.10
Sullivan et al15 (2013) Sit-and-reach, 2 ⫻ 10 seca31.7 0.2 33.6 9.2 0.20
Abbreviation: ROM, range of motion.
a Denotes signifi cant diff erence.
194 Copyright © SLACK Incorporated
Mauntel et al
Maintaining and regaining normal ROM is vital for
injury prevention and performance gains. Although not
all studies showed significant gains in ROM follow-
ing treatment,6,14 the majority of studies did (effect size
range = 0.20 to 1.33).7,9-11,13,15,22,26,28 Gains in ROM were
seen following single-treatment sessions,7,9,15,26 as well as
multiple-treatment sessions.10,11,13 These findings are fur-
ther supported by a study that was not included in the
formal review due to our inability to identify the data
necessary to calculate the effect sizes for the study. In that
study, Hou et al22 found significant gains in ROM fol-
lowing treatment of MTrPs with ischemic compression.
All but 1 study15 with statistically significant increases in
ROM had strong effect sizes (effect size range = 0.68 to
1.33), indicating both statistical and clinical significance.
Therefore, these findings are important for sports medi-
cine clinicians who want to increase their athletes’ ROM
prior to rehabilitation exercises, as well as strength and
conditioning professionals and athletes who want to in-
crease tissue extensibility prior to stretching or activity.
It is not surprising that 2 studies did not observe
a significant increase in ROM following treatment.
Mikesky et al14 studied well-trained athletes with normal
hamstring ROM and found that it is likely the athletes
reached a ceiling effect; thus, they did not significantly
increase their ROM following treatment (effect size =
0.50). Birmingham et al6 evaluated a population lacking
at least 10° of active knee extension, but they also did not
observe a significant gain in ROM (effect size = 0.14). In
both studies,6,14 only 1 treatment session was provided;
however, additional treatment sessions may be required
to produce a significant gain in ROM.8 No study re-
ported a significant decrease in ROM following myo-
fascial release therapies. These therapies may not always
result in gains in ROM, but nor do they inhibit it.
Gains in muscular activation and force production fol-
lowing myofascial release treatments would be ideal, as
these gains could increase movement efficiency and ath-
letic performance, but this does not appear to be the case.
However, myofascial release therapies do not decrease
muscular activation (effect size range = 0.04 to 0.28) or
force production.8,13,15 No changes were observed in force
production capabilities8,13,15 (effect size range = 0.01 to
0.46) or rate of force development (effect size range = 0.50
to 0.52).13 The weak-to-moderate effect sizes observed for
the studies reviewed indicate that the nonsignificant sta-
tistical differences are also not likely to be clinically sig-
nificant. This is further supported by Mikesky et al14 who
showed that National Collegiate Athletic Association
Division II athletes did not experience decreases in mea-
sures of athletic performance following an acute bout of
self-myofascial release. If myofascial release therapies did
inhibit muscular performance, they would not be an effec-
tive modality prior to the start of activity. Therefore, the
absence of muscular deactivation and reduction in force
development following myofascial release treatments is
of great importance to sports medicine clinicians, strength
and condition professionals, and athletes.
Myofascial release therapies do help to restore normal
muscular resting electrical activity.12,28 Pressure release
TABLE 4
Systematic Literature Review Muscular Activation Results
PRETREATMENT POSTTREATMENT
STUDY (YEAR) MEASUREMENT MEAN SD MEAN SD EFFECT SIZE
Drover et al8 (2004) Quadriceps inhibition, immediate 18.3 9.6 17.4 6.8 0.11
Drover et al8 (2004) Quadriceps inhibition, 20 min 18.3 9.6 16.8 6.6 0.18
MacDonald et al12 (2013) Quadriceps EMG, 2 min 0.3 0.2 0.2 0.1 0.06
MacDonald et al12 (2013) Quadriceps EMG, 10 min 0.3 0.2 0.3 0.2 0.00
Sullivan et al15 (2013) Hamstrings EMG, 1 ⫻ 5 sec 40.1 9.4 37.8 18.5 0.16
Sullivan et al15 (2013) Hamstrings EMG, 2 ⫻ 5 sec 37.7 21.6 41.1 28.1 0.14
Sullivan et al15 (2013) Hamstrings EMG, 1 ⫻ 10 sec 41.7 21.5 43.9 28.6 0.09
Sullivan et al15 (2013) Hamstrings EMG, 2 ⫻ 10 sec 39.8 16.6 40.5 18.6 0.04
Sullivan et al15 (2013) Hamstrings electromechanical delay, 1 ⫻ 5 sec 21.8 7.6 20.2 5.9 0.24
Sullivan et al15 (2013) Hamstrings electromechanical delay, 2 ⫻ 5 sec 21.0 6.1 21.7 4.6 0.13
Sullivan et al15 (2013) Hamstrings electromechanical delay, 1 ⫻ 10 sec 21.4 6.2 22.8 7.1 0.21
Sullivan et al15 (2013) Hamstrings electromechanical delay, 2 ⫻ 10 sec 21.0 4.9 22.9 8.1 0.28
Abbreviation: EMG, electromyography.
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Athletic Training & Sports Health Care | Vol. 6 No. 4 2014
Myofascial Release Therapies
therapy decreases spontaneous electrical activity imme-
diately surrounding MTrPs,12 as well as improves basal
electrical activity.28 These findings may shed light on how
myofascial release therapies are effective in increasing
ROM. Increased levels of spontaneous electrical activity
and basal electrical activity have been suggested to result
in decreased ROM, as they cause the muscle to be lo-
cally overactive while at rest and result in pain that may
cause individuals to compensate by voluntarily reduc-
ing ROM.12,28 Restoring normal resting muscle activity
would allow for the muscle to be stretched, potentially
reducing the pain associated with some MTrPs,12 and po-
tentially reducing deficits in muscular function, altered
neuromuscular properties, and decreased strength com-
monly associated with MTrPs and fascial restrictions.1-3
Of the studies reviewed and discussed, few utilized
multiple treatment sessions,10-13 3 evaluated the effective-
ness of myofascial release therapies in conjunction with
other modalities,10,12,22 8 evaluated pathologic popula-
tions,6,8-12,22,26 and 5 used a true randomized control trial
design.9-11,26,28 All of the studies described the therapy
used; however, only 3 mentioned the training of the clini-
cian or the athlete applying the therapy.7,13,15 Proper train-
ing and experience in myofascial release therapies is cru-
cial to optimizing therapeutic outcomes. It is evident that
additional research is needed to gain a better understand-
ing of the effects of myofascial release therapies on ROM,
muscular activation, and muscular force production.
Future Research
Future research should study pathologic populations,
as the previously mentioned therapies may be most ef-
fective in this group. In addition, studies utilizing mul-
tiple treatment sessions, as well as myofascial release
therapies, in conjunction with other modalities, are
vitally important because this is commonly performed
clinically.5,12,22 This is supported by Bell et al5 who re-
ported self-myofascial release in conjunction with static
stretching, followed by isolated strengthening of antag-
onistic muscles and functional exercises, was successful
in improving joint ROM and movement quality.5 Stud-
ies evaluating the length of time the benefits of myofas-
cial release therapies are present are also needed.
Study Limitations
The major limitation of the current systematic review is that
it focused only on physical, objectively measured effects
of myofascial release therapies. A number of studies both
included in and excluded from this review focused on the
effects of these therapies on pain and self-perceived perfor-
mance. These are important factors to consider because they
can limit an individual’s activity and performance. Also, this
review included only studies in which an effect size was able
to be calculated from the available data; additional studies,
which were discussed, provided further information on this
topic, but they were excluded from the formal review.
CONCLUSION AND IMPLICATIONS FOR CLINICAL
PRACTICE
The findings of this systematic review have practical ap-
plications for sports medicine clinicians, strength and
conditioning professionals, and athletes. The findings
of this study indicate that myofascial release therapies
are effective in restoring and increasing ROM, with-
TABLE 5
Systematic Literature Review Muscular Force Production Results
PRETREATMENT POSTTREATMENT
AUTHOR (YEAR) MEASUREMENT MEAN SD MEAN SD EFFECT SIZE
Drover et al8 (2004) Knee extension moment, immediate 165.0 65.0 159.0 51.0 0.10
Drover et al8 (2004) Knee extension moment, 20 min 165.0 65.0 156.0 55.0 0.15
MacDonald et al13 (2013) Quadriceps force, 2 min 727.5 101.3 692.8 98.5 0.35
MacDonald et al13 (2013) Quadriceps force, 10 min 727.5 101.3 683.9 86.9 0.46
MacDonald et al13 (2013) Quadriceps RFD, 2 min 566.3 99.7 496.2 171.3 0.50
MacDonald et al13 (2013) Quadriceps RFD, 10 min 566.3 99.7 517.3 89.1 0.52
Sullivan et al15 (2013) Hamstrings force, 1 ⫻ 5 sec 32.0 18.4 30.9 19.3 0.06
Sullivan et al15 (2013) Hamstrings force, 1 ⫻ 10 sec 32.6 16.9 30.6 18.9 0.11
Sullivan et al15 (2013) Hamstrings force, 2 ⫻ 5 sec 32.6 20.3 31.7 20.6 0.04
Sullivan et al15 (2013) Hamstrings force, 1 ⫻ 10 sec 32.5 17.7 32.6 19.5 0.01
Abbreviation: RFD, rate of force development.
196 Copyright © SLACK Incorporated
Mauntel et al
out having a detrimental effect on muscular activity or
performance. Gains in ROM allow for more efficient
movement patterns and ultimately result in better per-
formance and decreased risk of musculoskeletal injury.
These gains in ROM were observed with as little as
20 seconds of treatment15 but more commonly with 1.5
to 3 minutes of treatment.9-11,13,26
In addition, these findings are not limited to a single
population or a single therapy. The findings have been
shown across a variety of populations and therapies, and
were observed in both clinician and self-applied myofas-
cial release therapies. This implies that a skilled clinician
can teach an individual how to perform self-myofascial
release and that the individual will receive the same ben-
efits of the treatment, without using the clinician’s time.
This will allow the clinician to focus on other therapeutic
activities with 1 individual or with other individuals who
are receiving therapy or training at the same time. ■
REFERENCES
1. Barnes MF. The basic science of myofascial release: morphologic
change in connective tissue. J Bodyw Move Ther. 1997;1(4):231-238.
2. Schleip R, Klingler W, Lehmann-Horn F. Active fascial contractility:
fascia may be able to contract in a smooth muscle-like manner
and thereby infl uence musculoskeletal dynamics. Med Hypoth-
eses. 2005;65(2):273-277.
3. Schleip R, Naylor IL, Ursu D, et al. Passive muscle stiff ness may be
infl uenced by active contractility of intramuscular connective tis-
sue. Med Hypotheses. 2006;66(1):66-71.
4. Travell J, Simons D. Myofascial Pain and Dysfunction. Vol 1. Balti-
more, MD: Williams & Wilkins; 1983.
5. Bell DR, Oates DC, Clark MA, Padua DA. Two- and 3-dimensional
knee valgus are reduced after an exercise intervention in young
adults with demonstrable valgus during squatting. J Athl Train.
2013;48( 4):442-449. doi:10.4085/1062-6050-48.3.16
6. Birmingham TB, Kramer J, Lumsden J, Obright KD, Kramer JF. Eff ect
of a positional release therapy technique on hamstring fl exibility.
Physiotherapy Canada. 2004;56(3):165-170.
7. George JW, Tunstall AC, Tepe RE, Skaggs CD. The eff ects of active
release technique on hamstring fl exibility : a pilot study. J Manipu-
lative Physiol Ther. 2006;29(3):224-227.
8. Drover JM, Forand DR, Herzog W. Infl uence of active release tech-
nique on quadriceps inhibition and strength: a pilot study. J Ma-
nipulative Physiol Ther. 2004;27(6):408-413.
9. Grieve R, Clark J, Pearson E, Bullock S, Boyer C, Jarrett A. The immedi-
ate eff ect of soleus trigger point pressure release on restricted ankle
joint dorsifl exion: a pilot randomised controlled trial. J Bodyw Mov
Ther. 2011;15(1):42-49. doi:10.1016/j.jbmt.2010.02.005
10. Kannan P. Management of myofascial pain of upper trapezius: a
three group comparison study. Glob J Health Sci. 2012;4(5):46-52.
doi:10.5539/gjhs.v4n5p46
11. Sarrafzadeh J, Ahmadi A, Yassin M. The eff ects of pressure release,
phonophoresis of hydrocortisone, and ultrasound on upper
trapezius latent myofascial trigger point. Arch Phys Med Rehabil.
2012;93(1):72-77. doi:10.1016/j.apmr.2011.08.001
12. Kostopoulos D, Nelson AJ Jr, Ingber RS, Larkin RW. Reduc-
tion of spontaneous electrical activity and pain perception of
trigger points in the upper trapezius muscle through trigger
point compression and passive stretching. J Musculoskelet Pain.
2008;16(4):266-278.
13. MacDonald GZ, Penney MD, Mullaley ME, et al. An acute bout of
self-myofascial release increases range of motion without a subse-
quent decrease in muscle activation or force. J Strength Cond Res.
2013;27(3):812-821.
14. Mikesky AE, Bahamonde RE, Stanton K, Alvey T, Fitton T. Acute ef-
fects of the stick on strength, power, and fl exibility. J Strength Cond
Res. 2002;16(3):446-450.
15. Sullivan KM, Silvey DB, Button DC, Behm DG. Roller-massager
application to the hamstrings increases sit-and-reach range of
motion within fi ve to ten seconds without performance impair-
ments. Int J Sports Phys Ther. 2013;8(3):228-236.
16. D’Ambrogio K, Roth G. Positional Release Therapy: Assessment and
Treatment of Musculoskeletal Dysfunction. St. Louis, MO: Mosby; 1997.
17. Chaitow L. Positional release techniques in the treatment of mus-
cle and joint dysfunction. Clinical Bulletin of Myofascial Therapy.
1998;3:25-35.
18. Prentice W. Rehabilitation Techniques for Sports Medicine and Ath-
letic Training. 4th ed. New York, NY: McGraw-Hill; 2005.
19. Prentice W. Arnheim’s Principles of Athletic Training: A Competency-
Based Approach. 12th ed. New York , NY: McGraw-Hill; 2006.
20. Simons D. Understanding eff
ective treatments of myofascial trig-
ger points. J Bodyw Move Ther. 2002;6(2):81-88.
21. Moraska A, Hickner R, Kohrt W, Brewer A. Changes in blood fl ow
and cellular metabolism at a myofascial trigger point with trigger
point release (ischemic compression): a proof-of-principle pilot
study. Arch Phys Med and Rehabil. 2013;94(1):196-200. doi:10.1016/j.
apmr.2012.08.216
22. Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Immediate ef-
fects of various physical therapeutic modalities on cervical myo-
fascial pain and trigger-point sensitivity. Arch Phys Med Rehabil.
2002;83(10):1406-1414.
23. Vulfsons S, Ratmansky M, Kalichman L. Trigger point needling:
techniques and outcome. Curr Pain Headache Rep. 2012;16(5):407-
412. doi:10.1007/s11916-012-0279-6
24. Cohen J. Statistical Power Analysis for Behavioral Sciences. 2nd ed.
Hillsdale, NJ: Lawrence Erlbaum; 1988.
25. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Re-
liability of the PEDro scale for rating quality of randomized con-
trolled trials. Phys Ther. 2003;83(8):713-721.
26. Oliveira-Campelo NM, de Melo CA, Alburquerque-Sendin F,
Machado JP. Short- and medium-term eff ects of manual therapy
on cervical active range of motion and pressure pain sensitivity in
latent myofascial pain of the upper trapezius muscle: a random-
ized controlled trial. J Manipulative Physiol Ther. 2013;36(5):300-309.
doi:10.1016/j.jmpt.2013.04.008
27. O’Sullivan K, McAuliff e S, Deburca N. The eff ects of eccentric train-
ing on lower limb fl exibility: a systematic review. Br J Sports Med.
2012;46(12):838-845. doi:10.1136/bjsports-2011-090835
28. Aguilera FJ, Martin DP, Masanet RA, Botella AC, Soler LB, Morell
FB. Immediate eff ect of ultrasound and ischemic compression
techniques for the treatment of trapezius latent myofascial trig-
ger points in healthy subjects: a randomized controlled study.
J Manipulative Physiol Ther. 2009;32(7):515-520. doi:10.1016/j.
jmpt.2009.08.001
