Acute effect of self-myofascial release using a foam roller on the plantar fascia on hamstring and lumbar spine superficial back line flexibility

Abstract

Objective: The purpose of this study was to investigate the immediate effect of applying self-myofascial release (SMR) to the
plantar fascia using a foam roller on hamstring and lumbar spine superficial back line (SBL).
Design: Randomized controlled trial.
Methods: Thirty-one healthy adults agreed to the method and purpose of the study. Selection and exclusion criteria were
screened, and baseline measurements for the Toe Touch test and passive straight leg raise (PSLR) test were obtained. The participants
were then randomly assigned to the SMR group or the sham group. After group assignment, the SMR group rolled the surface
of the foot from the heel to the metatarsal head using a foam roller for 5 minutes. The sham group received passive mobilization
of the ankle joint in the supine position. Afterwards, the Toe Touch test and the passive straight leg-raise test were
re-assessed.
Results: In the SMR group, the Toe Touch test results showed significant improvement (p<0.05). Left and right PSLR test results
showed a significant increase (p<0.05). In the sham group, there was no significant difference between pre and post-test results.
The SMR group showed a significant difference in the PSLR test and Toe Touch test compared to the sham group (p<0.05).
Conclusions: The results of this study showed that SMR on the plantar fascia was immediately effective for improving the flexibility
of the SBL of the lumbar spine and hamstring.

Full text

http://crossmark.crossref.org/dialog/?doi=10.14474/ptrs.2018.7.1.35&domain=pdf&date_stamp=2018-03-25
Received: 17 January, 2018 Revised: 12 March, 2018 Accepted: 13 March, 2018
Corresponding a uthor: Jongeun Yim (ORCID http://orcid.org/0000-0001-7510-8233)
Department of Physical Therapy, College of Health Science and Social Welfare, Sahmyook University, 815 Hwarang-ro, Nowon-gu, Seoul 01795, Republic of
Korea
Tel : 82-2-3399-1635 Fax: 82-2-3399-1639 E-ma il: jeyim@syu.ac.kr
This is an Open-Access article distribut ed under the terms of the Creative Commons Attribution Non-Commercial License (htt p://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2018 Korean Academy of Physical Therapy Rehabilitation Science
https://doi.org/10.14474/ptrs.2018.7.1.35
pISSN 2287-7576
eISSN 2287-7584
Phys Ther Rehabil Sci
2018, 7 (1), 35-40
www.jptrs.org
Acute effect of self-myofascial release using a foam roller
on the plantar fascia on hamstring and lumbar spine
superficial back line flexibility
Kwangsun Doa, Jaeeun Kimb, Jongeun Yimc
aDepartment of Physical Therapy, International St. Mary's Hospital, Catholic Kwandong University, Incheon, Republic of Korea
bDepartment of Physical Therapy, Barosun Hospital, Seoul, Republic of Korea
cDepartment of Physical Therapy, College of Health Science and Social Welfare, Sahmyook University, Seoul, Republic of Korea
Objective:
The purpose of this study was to investigate the immediate effect of applying self-myofascial release (SMR) to the
plantar fascia using a foam roller on hamstring and lumbar spine superficial back line (SBL).
Design:
Randomized controlled trial.
Methods:
Thirty-one healthy adults agreed to the method and purpose of the study. Selection and exclusion criteria were
screened, and baseline measurements for the Toe Touch test and passive straight leg raise (PSLR) test were obtained. The partic-
ipants were then randomly assigned to the SMR group or the sham group. After group assignment, the SMR group rolled the sur-
face of the foot from the heel to the metatarsal head using a foam roller for 5 minutes. The sham group received passive mobi-
lization of the ankle joint in the supine position. Afterwards, the Toe Touch test and the passive straight leg-raise test were
re-assessed.
Results:
In the SMR group, the Toe Touch test results showed significant improvement (p<0.05). Left and right PSLR test results
showed a significant increase (p<0.05). In the sham group, there was no significant difference between pre and post-test results.
The SMR group showed a significant difference in the PSLR test and Toe Touch test compared to the sham group (p<0.05).
Conclusions:
The results of this study showed that SMR on the plantar fascia was immediately effective for improving the flexi-
bility of the SBL of the lumbar spine and hamstring.
Key W ords:
Plantar fascia, Range of motion, Self-myofascial release, Superficial back line
Introduction
Flexibility can be defined as the ability for muscle stretch
to enable movement of a joint as far as the range of motion,
which is an essential component of normal biomechanical
function [1]. A change in flexibility is necessary for all
movements because it can cause abnormal loads and result
in damage to the musculoskeletal system [2,3]. One of the
factors that cause damage to the lines of the musculoskeletal
system is insufficient flexibility [4,5].
The thin sheets of fascia and connective tissue fibers that
form a line can form a pathway, which is called the my-
ofascial meridians. Among them, the superficial back line
(SBL) is a plantar aponeurosis, achilles tendon and gastro-
cnemius, popliteus, hamstring, sacrotuberous ligament, sac-
rolumbar fascia, erector spinae, and galea aponeurotica/epi-
cranial fascia. The SBL functions as a single continuous line
with integrated muscle fascia. For example, plantar fasciitis
is associated with tachypnea tension, lumbar lordosis, and
resistance to superficial cervical spondylosis [6,7]. Because
Original Article

36
Phys Ther Rehabil Sci 7(1)
Figure 2. Position of the foam roller on the plantar fascia during
self-myofascial release.
Table 1. General characteristics (N=31)
Characteristic SMR group (n=15) Sham group (n=16)
Sex (male/female) 10/5 9/7
Height (cm) 170 (7.68) 168.4 (7.44)
Weight (kg) 65.73 (10.55) 60.18 (11.88)
Age (y) 30.53 (3.6) 23.93 (4.9)
Values are presented as number only or mean (SD).
SMR: self-myofascial release.
Figure 1. Micro foam roller (Ristroller, USA). The micro foa
m
roller is device designed for release the forearm and plantar fasci
a
with rolling motion. Small design of Foam rollers, commonly
known as fascia relaxation.
the hamstring and calf muscles are a connected continuity,
the reduced flexibility and stiffness of the hamstring may be
the cause of plantar fasciitis [8].
There are several methods for increasing the flexibility of
the fascia including the Rolfing, instrument-assisted fascial
release, connective tissue massage, myofascial trigger point
therapy, muscle energy techniques, and strain-counter strain
[9]. One of the most common manipulative techniques, the
myofascial release (MFR), helps to reduce fibrous adhesion
or limited membrane between fascial tissue layers [10]. The
self-myofascial release (SMR) has the same theory as the
MFR, which can be applied by self under the supervision of
a therapist [11]. It has been developed from the myofascial
release as a principle that stimulates the muscles, tendons,
and mechanoreceptors of the fascia and biomechanically
loads the soft tissues [12]. The Golgi tendon organ (GTO)
reflex arc model and other mechanoreceptors are the two
mechanisms for increasing fascia mobilization using SMR.
When the muscles are stretched, GTOs provide afferent
feedback to the spinal cord. As pressure increases in the fas-
cia by MFR or SMR, it stimulates GTOs, which reduces the
motor unit firing rate and consequently reduces muscle tone
[13]. The Ruffini and Pacinian corpuscles and the interstitial
muscle receptors are the mechanoreceptors that are also in-
volved in the neurophysiological mechanism for increasing
fascia mobilization using SMR [14]. As pressure increases,
the mechanical receptors stimulate the nervous system,
thereby reducing muscle tone [15].
In previous studies, many studies have been conducted to
improve flexibility using SMR [10,11,16-20]. Studies have
focused mainly on the muscles that are to be increased.
According to Anatomy Trains [7], there is a way to observe
the association of the SBL. Myers [7] advocates that the ef-
fect of SBL can be seen through a simple test of rolling a ten-
nis ball or golf ball on the plantar fascia. Relaxing the plantar
fascia has additional effects on the hamstring and lumbar
spine, which have the same myofascial train. This means
that when one part of the body is relaxed, it affects the other
connected fascia. However, this proposal has had some clin-
ical effects, and no evidence has been provided through for-
mal studies.
Therefore, the purpose of this study was to investigate the
immediate effect of applying SMR to the plantar fascia us-
ing foam roller on hamstring and lumbar spine.
Methods
Subjects
Thirty-one healthy adults agreed to the method and pur-
pose of the study. The selection criterion was defined as hav-
ing no problems in the back and lower back, pain, sensory

Do, et al: SMR of plantar fascia using foam roller and myofascial meridian
37
Figure 4. Passive straight leg raise.Figure 3. Toe Touch test.
abnormality, and other lower extremity and lumbar prob-
lems within the past 6 months. In addition, the Toe Touch
test excluded those who could reach the floor. The character-
istics of the study subjects are shown in Table 1.
This study was approved by the Institutional Review
Board of the Sahmyook University (IRB No. 2-1040781-
AB-N-01-2018009HR).
Procedure
The selection and exclusion criteria were screened, and
Toe Touch test and passive straight leg raise (PSLR) test
baseline were measured. The participants were then ran-
domly assigned to the experimental group (SMR) or control
group (Sham) and randomly used the online tool “Graph
Pad” (GraphPad Software, San Diego, CA, USA; http://
www.graphpad.com/quickcalcs/randomize1.cfm/). After gr-
oup assignment, the SMR group rolled the surface of the foot
from the heel to the metatarsal head for 5 minutes using a
foam roller (Figures 1, 2) [21]. Participants were instructed
to apply as much pressure as possible without pain [22].
Then, the Toe Touch test and the PSLR were re-measured.
The sham group received passive mobilization of the ankle
joint while being in a supine position. Passive movements
applied in a randomized order were supination, pronation,
abduction, adduction, flexion, and extension. Subjects were
given 5 minutes of mobilization [23].
Outcome measures
Toe Touch test
Subjects were asked to stand up straight on a 20-cm high
platform with feet together and no shoes. Then, the subjects
were instructed to bend down towards the platform as much
as possible while keeping the knees, arms, and fingers in full
extension. (Figure 3). The distance from the tip of the middle
finger and the platform was measured in centimeters with a
supple measuring tape. If the tip of the middle finger could
not reach the platform, the test was considered positive. If
the subject could reach past the platform, the test was con-
sidered negative. Both evaluators were experienced in
measuring the finger-to-floor distance. The intra-class cor-
relation coefficient (ICC) of the Toe Touch test was 0.99.
The Spearman’s correlation coefficient for trunk flexion as-
sessed by the test and the radiologic measure was −0.96
[24].
Passive straight leg raise
PSLR was conducted with the subject in supine position
on a medical bed. The examiner performed the PSLR by
keeping the knee in full extension and the ankle in neutral
position. Full ankle dorsiflexion was avoided to prevent calf
muscle stiffness or pain (gastrocnemius and soleus) from
confounding the sensation of hamstring stiffness and pain,
which would signal the limit of the PSLR test. The examiner
stabilized the talus in order to prevent any hip rotation during
hip flexion. The examiner lifted the subject's lower limb un-
til the subject began to complain of pain or stiffness in the
thigh region, perform knee flexion, or swing into a posterior
pelvic tilt position (noted as movement of the anterior supe-
rior iliac spine). Range of motion measurements for the
PSLR were taken using Clinometer (Plaincode, Stephan-

38
Phys Ther Rehabil Sci 7(1)
Table 2. Comparison of PSLR and Toe Touch test
b
etween
two groups (N=31)
Variable SMR group
(n=15)
Sham group
(n=16) t (p)
Left PSLR
Pre-test 45.6 (7.10) 51.43 (10.25) −1.83 (0.07)
Post-test 54.13 (8.12) 52.06 (10.20) 0.62 (0.53)
t (p)−6.95 (<0.001) −0.59 (0.56)
Change value 8.53 (4.74) 0.62 (4.20) 4.91 (<0.001)
Right PSLR
Pre-test 45.27 (5.99) 49.93 (7.46) −1.91 (0.06)
Post-test 53.73 (8.87) 48.43 (8.64) 1.68 (0.10)
t (p)−5.66 (<0.001) 1.66 (0.11)
Change value 8.46 (5.79) −1.50 (3.61) 5.78 (<0.001)
Toe Touc h te st
Pre-test 17.88 (6.98) 17.76 (9.59) 0.39 (0.96)
Post-test 13.22 (6.91) 16.28 (8.37) −1.10 (0.27)
t (p) 6.76 (<0.001) 2.11 (0.05)
Change value −4.66 (2.66) −1.47 (2.78) −3.24 (<0.001)
Values are presented as mean (SD).
PSLR: passive straight leg raise, SMR: self-myofascial release.
skirchen, Germany; http://www.plaincode.com/products/clin-
ometer/), which is a smart phone application that has pre-
viously been shown to be reliable at measuring range of mo-
tion of the shoulder. The intra-observer reliability of the
smartphone inclinometric and goniometric measurements
was ICC value >0.9 [25]. The upper part of the patella was
marked and the end of the smart phone was aligned (Figure
4).
Statistical analysis
Results were analyzed using the SPSS ver. 15.0 (SPSS
Inc., Chicago, IL, USA). For the general subject character-
istics, the descriptive statistics was conducted. To examine
the changes in PSLR and Toe Touch results before and after
intervention, the paired t-test was performed. To compare
the PSLR and Toe Touch test results between the SMR and
the Sham group, the independent t-test was performed. The
statistical significance was assumed to be α=0.05.
Results
This study selected 31 healthy adults who passed the se-
lection criteria. The general characteristics are shown (Table 1).
Before the experiment, there were no significant differ-
ences in PSLR and Toe Touch test results between the SMR
group and the Sham group (Table 2). In the SMR group, the
Toe Touch test results showed a significant improved, from
17.88 to 13.22 (p<0.05). Left PSLR significa ntly increased
from 45.6 to 54.13 (p<0.05). Right PSLR significantly in-
creased from 45.27 to 53.73 (p<0.05). In the Sham group,
there were no significant differences between pre and post
test. The SMR group showed a significant difference in
PSLR and Toe Touch test results compared to the Sham
group (p<0.05; Table 2).
Discussion
There is a hypothesis that an increase in muscle tension in
one part of the body causes excessive tension in other parts
of the body due to the continuity of the body. This continuity
of the fascia can cause stress on not only the muscles but all
the structures that are surrounded and supported by the fas-
cia [7]. Based on this hypothesis and anatomy, Myers [7]
supported the increase in the Toe Touch test when the plantar
fascia at the end of the SBL was released. However, some
clinical effects were claimed and there were no formal
studies. Therefore, the purpose of this study was to inves-
tigate the effect of performing SMR to the plantar fascia on
hamstring and lumbar spine flexibility.
The PSLR and Toe Touch results of the SMR group were
significantly increased after intervention (p<0.05) and also
showed a significant difference compared to the Sham
group. There was no significant difference in the Sham
group pre and post intervention. These results suggest that
the SMR of the plantar fascia was immediately effective for
the lumbar and hamstring flexibility. There have been many
studies on the effect of SMR on the range of motion and flex-
ibility [10,11,20,26]. However, previous research on in-
creasing flexibility has been limited to selected parts of the
body. There has been no research showing the effects of ap-
plying SMR to one part of the body may affect other parts of
the body. According to the Anatomy Trains [7], SMR ap-
plied to the plantar fascia is effective in increasing flexibility
anywhere along the SBL, but no evidence has been sug-
gested through formal studies. However, this study found
that the application of SMR using a foam roller to the plantar
fascia could support the concept of increased flexibility of
other body parts connected by myofascial meridians such as
hamstring and lumbar spine.
Although we did not use SMR, there are some studies that
have experimented with the concept of myofascial meri-
dians. An RCT investigated the effects of hamstring passive
stretching on the range of motion of the neck in healthy

Do, et al: SMR of plantar fascia using foam roller and myofascial meridian
39
adults. The range of motion of the cervical, which is the as-
cending part of SBL, increased after hamstring stretching
[27]. According to Spina [28], a patient with chronic ham-
string pain was relieved of pain and dysfunction by applying
an active release technique to the SBL, the lumbar spine, and
calf. Akhbari et al. [29] reported that a patient with chronic
plantar fasciitis was treated with dry needling on the
Achilles tendon, medial gastrocnemius, biceps femoris,
semimembranosus, and ischial tuberosity. After 4 treat-
ments over 2 weeks, the patient showed a 60% to 70% reduc-
tion in pain.
Many anatomical books have described the function of
muscles as separate from adjacent structures, excluding the
upper and lower connective muscles, nerves and blood
vessels. For example, it is simply defined that the distance
between the origin and the insertion point of a particular
muscle is close to the function of the muscle. Separate think-
ing of the muscles makes it difficult for current-generation
therapists to have different views on the function of muscles
and muscles [7]. This is similar to the view that clinicians
limit the treatment to the area of pain or discomfort. In the fu-
ture, it will be possible to get more effective treatments if
you use a mixture of extended concepts such as myofascial
meridian.
The limitation of this study is the lack of the number of ex-
perimental groups. Secondly, there is a lack of clinically rel-
evant thinking about the application to healthy adults. In the
future, it is hoped that further studies will be conducted to in-
vestigate the effects of the disease on pain and function.
The results of this study showed that SMR on the plantar
fascia was immediately effective for improving the flexi-
bility of the SBL of the lumbar spine and hamstring. These
results suggest that in order to increase flexibility, inter-
ventions should be made not only to the body part but also to
other parts of the body, taking into account the continuity of
the myofascial meridian.
Conflict of Interest
The authors declared no potential conflicts of interest
with respect to the authorship and/or publication of this
article.
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