The Effects of Tissue Flossing on Perceived Knee Pain and Jump Performance: A Pilot Study

Abstract

BACKGROUND: Tissue compression and partial vascular occlusion using band flossing results in reperfusion of blood to the muscle tissue that may ultimately reduce joint pain and increase range of motion, enhancing prevention from or rehabilitation of injury. However, the extent of research examining the effect of tissue flossing in an athletic setting is currently very limited, and the effects of band flossing on knee pain and jump performance have not yet been investigated and remain unclear. PURPOSE: To investigate the effect of band flossing on perceived knee pain and vertical jump performance in recreational athletes with knee pain. METHODS: Five young male recreational athletes with previously reported knee pain took part in this study (age 22±0.5; height 184±6.8cm; weight 79±1.5kg; BMI 23.34±1.2 kg/m2). Participants performed a number of tests pre and post intervention, with the application of a floss band on the knee joint. The experimental protocol consisted in the performance of countermovement jump (CMJ) tests (without occlusion, with occlusion, and after occlusion). Pre and Post intervention measures included a perceived knee pain -by visual analogue scale (VAS)- and CMJ performance -by force platform-. RESULTS: The application of flossing bands in knee joint resulted in enhancements in all test measures pre to post intervention (10% jump height; 4.5% time in the air; 5% jump velocity; 13% jump power; 7.5% jump force). Participants reported a 3.5-point pain enhancement in AVS during performance of CMJ tests. CONCLUSION: Flossing bands caused a reduction in perceived knee pain and improved vertical jump performance in young male recreational athletes.

Full text

International Journal of Human Movement and Sports Sciences 8(2): 63-68, 2020 http://www.hrpub.org
DOI: 10.13189/saj.2020.080203
The Effects of Tissue Flossing on Perceived Knee Pain
and Jump Performance: A Pilot Study
García-Luna Marco A., Cortell-Tormo Juan M.*, González-Martínez Julián, García-Jaén Miguel
Area of Physical Education and Sport, University of Alicante, Spain
Received January 12, 2020; Revised February 11, 2020; Accepted February 24, 2020
Copyright©2020 by authors, all rights reserved. Authors agree that this article remains permanently open access under
the terms of the Creative Commons Attribution License 4.0 International License
Abstract Background: Tissue compression and
partial vascular occlusion using band flossing results in
reperfusion of blood to the muscle tissue that may
ultimately reduce joint pain and increase range of motion,
enhancing prevention from or rehabilitation of injury.
However, the extent of research examining the effect of
tissue flossing in an athletic setting is currently very limited,
and the effects of band flossing on knee pain and jump
performance have not yet been investigated and remain
unclear. Purpose: To investigate the effect of band
flossing on perceived knee pain and vertical jump
performance in recreational athletes with knee pain.
Methods: Five young male recreational athletes with
previously reported knee pain took part in this study (age
22±0.5; height 184±6.8cm; weight 79±1.5kg; BMI
23.34±1.2 kg/m2). Participants performed a number of
tests pre and post intervention, with the application of a
floss band on the knee joint. The experimental protocol
consisted in the performance of countermovement jump
(CMJ) tests (without occlusion, with occlusion, and after
occlusion). Pre and Post intervention measures included a
perceived knee pain -by visual analogue scale (VAS)- and
CMJ performance -by force platform-. Results: The
application of flossing bands in knee joint resulted in
enhancements in all test measures pre to post intervention
(10% jump height; 4.5% time in the air; 5% jump velocity;
13% jump power; 7.5% jump force). Participants reported
a 3.5-point pain enhancement in AVS during performance
of CMJ tests. Conclusion: Flossing bands caused a
reduction in perceived knee pain and improved vertical
jump performance in young male recreational athletes.
Keywords Floss Bands, Vascular Occlusion, Joint
Pain, Countermovement Jump, Patellofemoral
1. Introduction
In recent years, the use of compressive materials has
grown considerably, both for the improvement of physical
performance and for health. This boom is due, to a greater
extent, to the benefits provided by their use. For its correct
application, different types of garments and/or
compressive materials have been developed that respond to
different areas and objectives.
One of the most widespread compressive materials are
compressive garments. Their origin comes from the health
field and it has been demonstrated that they have positive
effects on the blood circulation of the extremities [1,2]. In
the field of sports, it has been proven that the prolonged use
of compressive garments has improved performance in
different sports [3–5]. The possible explanation would be
its positive effects on venous hemodynamics [6], decreased
exercise-induced muscle damage [7–9], and its possible
contribution to recovery [8,10–12]. There are different
types of compression garments, stockings, sleeves, upper
body garments (covering the torso and upper limbs
completely or partially) and lower body garments (from the
waist, covering the lower limbs completely or partially)
[13].
Another compressive material whose use has grown
exponentially in recent years in the field of strength
training, are occlusion cuffs. Unlike garments, these apply
a band (inflated, elastic or rigid) to the area closest to the
extremities with the intention of restricting the blood flow.
Strength training with blood flow restriction (BFR) has
shown significant gains in hypertrophy [14–16] and muscle
strength [15,17–19]. In addition, these benefits are
obtained by training at low intensity (loads around 20-40%
of 1RM). It is therefore a very useful method for sectors of
the population that, for health reasons, do not tolerate high
loads on their joints and must improve their strength and
hypertrophy [17,20–22].
On the other hand, recently a new material and method
has been incorporated to compress the joints by means of
an elastic band called flossing or floss band [23]. This
consists of the use of reusable rubber bands with the aim of
compressing a muscle region or a joint. Its purpose is to

64 The Effects of Tissue Flossing on Perceived Knee Pain and Jump Performance: A Pilot Study
improve the range of motion (ROM), restore the mechanics
of the joints and decompose the adhesive tissue of the
previously injured musculature.
There is scientific evidence that supports its use to
increase ROM [24–26] and pain reduction [24,27].
However, these results are not conclusive as there are other
studies in which no improvement has been observed in
these two variables [28,29]. Most studies have applied the
flossing band to the ankle [25,26,30,31], the shoulder [29],
or the wrist [24]. Only in one case has it been applied to the
knee and improvements in strength were observed [32].
Concurrently, one of the most common knee problems is
patellofemoral pain syndrome (PFPS), which is
characterized by the presence of peripatellar or anterior
knee pain [33], affecting one in four people [34,35], and
also being responsible for a high percentage of knee sports
injuries [36]. For that reason, it would be helpful to find a
non-invasive way to improve this issue.
The effects of the flossing band on ROM, performance
and knee pain are unknown, but since improvements have
been seen in other joints [24,27], and other therapies
similar to flossing band, such as bandaging techniques
(Infrapatellar, Kinesiotape or McConnell), have been
shown to help reduce painful symptoms and improve
muscle function and strength [37–41], flossing band could
probably also be applicable to the knee joint.
Therefore, the objective of this work is to investigate the
effect of elastic bands (flossing) on perceived knee pain
and vertical jump performance in amateur athletes with
PFPS.
2. Materials and Methods
2.1. Participants
Five young male recreational athletes with PFPS took
part in this study (age= 22.0±0.5 years; height= 184.1±6.8
cm; weight= 79.0±1.5 kg; BMI= 23.34±1.20 kg/m2). To
be eligible for this study, they all had to have been
diagnosed with the PFPS for at least three months, but no
known knee injury. They all had strength training
experience and signed an informed consent form prior to
any intervention or data collection. Candidates who could
be adversely affected (cardiovascular or joint health) by
the intervention in the study were excluded.
2.2. Procedure
The participants performed a pre and post test, with or
without application of a floss band (Life Floss bands,
Sydney, Australia) on the painful knee. Two different days
(intervention and control) were used to carry out the
protocol, using the application of the floss band in the first
of them, and eliminating its use in the second. The aim of
the separation into two days was to rule out that the
application of one protocol would affect the results of the
next.
On the first day (FLOSS) three series of three counter
movement jumps (CMJ) were performed, with the average
of the three jumps in each series. CMJ was performed from
an upright position with straight legs, beginning the jump
with a counter movement down to a knee angle of 90
degrees. Hands were held on the waist during the whole
jump to avoid any effect of arm-swing. We used 1-minute
rest between series, and 15 seconds between repetitions. 1st
series: without application of floss band (PRE); 2nd series:
with application of floss band (FB) (Figure 1); 3rd series:
without application of floss band, after removal (POST).
On the second day (CON), the same protocol was
performed, but without the application of floss band: three
series (S1, S2 and S3) of three CMJ with 1-minute rest
between series and 15 seconds between repetitions. The
same jump performance and perceived pain variables were
measured on both days.
Figure 1. CMJ with floss band
2.2.1. CMJ
Each participant performed the CMJs with their hands
on their waist, starting from an upright position and
keeping their legs extended throughout the flight phase.
Variable jump height, time in the air, jump velocity, jump
power and applied force were measured using a force
platform (Kistler 9287 BA, Kistler Instruments Ltd., Hook,
UK).
Perceived knee pain was also measured in all three
phases of the protocol. Each phase corresponds to the
perceived pain at the end of each series of three CMJs. A
visual analogue scale (VAS) divided into 10 equal parts
(indicating 0 as no pain and 10 as unbearable pain) was
used for assessment.

International Journal of Human Movement and Sports Sciences 8(2): 63-68, 2020 65
2.2.2. Floss Band Application
The painful knee was bandaged according to the
manufacturer, surrounding it from the most proximal to
the most distal area, leaving 30% of the band visible and
overlapping along the joint (Figure 2). To ensure that the
pressure of the band was adequate, the Kikuhime pressure
measuring sensor (MediGroup, Melbourne, Australia),
located between the band and the lateral condyle of the
femur, was used. The average pressure was 182±38
mmHg.
Figure 2. The floss band knee bandaging technique used
2.3. Statistical Analysis
Data analysis was performed using the IBM SPSS
Social Science Statistical Package, version 25.0 (SPSS
Inc., Chicago, IL, USA). The sample distribution was
tested using the Shapiro-Wilk test. A T-Student test was
performed to check if there were significant differences. A
value of p<0.05 was established to determine statistical
significance.
3. Results
Significant differences were found in all the analysed
variables regarding the performance of the vertical jump in
the protocol applying the floss bands (p<0.05). No
significant differences were found in any of the variables
analysed related to the vertical jump performance in the
protocol that did not apply the floss bands (p=0.283).
Significant differences in perceived pain were found in the
protocol applying the floss bands (p<0.001). No significant
difference in perceived pain was found in the protocol that
did not apply floss bands (p=0.413). Table 1 presents these
results.
All variables were evaluated during the three series of
jumps, although significant differences were only found
between the first and third series. Thus, the application of
the floss bands was found to significantly improve the
performance of the CMJ, as well as significantly reduce the
perception of pain in the knee where the floss bands were
applied, but not during their application, but after their
removal.
Table 1. Pre, FB and Post (or S1, S2, S3) measures (mean ± SD) and percentage of variation, in the two days of intervention
FLOSS (mean ± SD) CON (mean ± SD)
PRE FB POST ∆ (%) S1 S2 S3 ∆ (%)
JH (cm) 36.03±5.21 36.39±7.09 40.02±5.60 11.1±1.4* 31.69±4.45 31.46±5.12 32.61±4.73 2.9±0.8
TA (s) 0.542±0.076 0.549±0.081 0.571±0.082 5.4±0.7* 0.508±0.071 0.498±0.079 0.521±0.074 2.6±0.5
JV (m/s) 1.33±0.19 1.34±0.21 1.41±0.20 6.0±0.8* 1.25±0.18 1.24±0.21 1.28±0.18 2.4±0.4
JP (W) 3837±537 3852±539 4371±612 13.9±1.8* 3280±460 3257±441 3389±497 3.3±0.9
JF (N) 2886±404 2895±412 3121±437 8.1±1.1* 2630±368 2614±349 2697±386 2.5±0.7
AVS 1-10 4.0±0.7 3.8±0.5 0.5±0.5 -87.5±9.7** 6.0±0.7 5.5±0.8 5.2±0.5 -13.3±7.7
FLOSS= Day when floss band protocol was applied; CON= Control day in which the protocol was performed without the floss bands;
PRE= Without application of floss band; FB= With application of floss band; POST= After removal of floss band; S1,S2,S3= Series 1,2,3;
JH= Jump height; TA= Time in the air; JV= Jump velocity; JP= Jump power; JF= Jump force; AVS (1-10)= Analogue visual scale.
* The differences are significant (Pre vs Post p<0.05).
** The differences are significant (Pre vs Post p<0.001).

66 The Effects of Tissue Flossing on Perceived Knee Pain and Jump Performance: A Pilot Study
4. Discussion
The aim of this work was to identify whether the
application of the floss band to the knee joint could
increase the performance of the CMJ and decrease the
sensation of pain in this joint.
Different studies have shown the benefits of floss bands,
although the vast majority have used them on joints other
than the knee. Stevenson et al. [25] showed that, by
compressing the ankle joint for 2 minutes, significant
improvements were achieved in dorsiflexion of this joint
(p<0.032). Driller & Overmayer [26], also found
significant improvements in ankle ROM and one-leg
jumping performance (p<0.01). The same research group
in a later work found, in agreement with the previous one,
that the application of the floss bands in both ankles during
2 minutes, could improve the performance in the ROM, the
CMJ and the sprint until 45 minutes after its application
[30]. However, although significant differences were found
in ankle ROM (p<0.05), both CMJ and sprint performance
were not (p>0.05). Very similar results were obtained by
Mills et al. [31], finding improvements in ankle ROM,
CMJ and sprint performance, although not significant in
the latter two (p<0.05).
Floss bands have also been applied to other joints, such
as the shoulder, in order to analyse their influence on ROM
and their power in the bench press movement [29].
Although no significant differences were found in any of
these variables, the authors suggest that floss bands may
have a greater influence on less complex joints than the
shoulder. They attribute this lack of efficacy to the
deficiency of the bandage to compress all the muscles
involved in the movements evaluated. On the other hand,
the wrist has also been analysed, in a case study based on a
participant with "Kienböck disease" (aseptic avascular
necrosis of the crescent carpal), who presented pain and
swelling on the right wrist dorsum [24]. In this work, the
influence of the floss band on pain reduction and
improvement of wrist functionality in aspects of daily life,
such as pain, numbness, tingling, ability to drive or work,
was analysed by means of questionnaires. After 6 weeks of
application of the floss band treatment (1-3 minutes of
application before your rehabilitation exercises),
significant improvements in both pain perception and wrist
functionality were found (p<0.05).
Although the use of the floss band is recent, different
modes of compression or bandaging have shown benefits
for decades. Patellar taping, for example, showed a
significant decrease in pain (p<0.005) and an increase in
performance in the Star Excursion Balance Test in patients
with PFPS [39]. Kuru et al. [41] concluded that Kinesio
bands showed the same benefits as electrostimulation in
patients with PFPS, in terms of pain reduction, improved
ROM, strength, functional capacity and quality of life. It is
relevant to mention that both works, contrary to our results,
showed the benefits during the application of the band,
while in the present work the improvements came after
removing the floss band.
Mason et al. [37], on the other hand, also found benefits
in pain reduction in patients with PFPS by means of
infrapatellar taping, being applied continuously throughout
the week. However, their results concluded that greater
benefits are obtained when combined with quadriceps
stretching and strengthening work. Similar results were
evidenced by Paoloni et al. [40], where they suggested that
a short period (14 days) of patellar taping and a subsequent
exercise program was a good means of controlling
long-term pain in participants with PFPS associated with
muscle dysfunction.
Although it is complicated to allude to the
physiological or mechanical mechanisms that could have
favoured the changes described, it seems that our results
are in the same direction as other previous work that has
used this type of implement or some similar ones.
Therefore, it is suggested that future research will be able
to identify what these mechanisms are, as well as to
provide more evidence and clarity to joint compression by
means of floss bands.
5. Practical Applications
Other studies have shown the importance of good ankle
dorsiflexion in shock absorption in the lower extremities
when landing a jump [42], thus justifying the use, prior to
exercise, of floss bands on the ankle [30]. Therefore, the
previous results, as well as those obtained in this study
suggest that there could be powerful and useful practical
applications, considering the use of floss bands during the
warm-up prior to training, or even competition. This
would be a good method to reduce pain produced by
PFPS, as well as to increase performance in vertical
jumping. Any sport or physical activity in which vertical
jumping is a performance factor could benefit greatly
from this type of technique, although future research
should establish which protocol produces the greatest
gains in these variables.
6. Conclusions
The present study adds useful and interesting
information to the novel field of floss bands, in relation to
the reduction of knee pain in participants with PFPS and
the increase in CMJ performance. Both variables have
been improved after the application of these bands and
their subsequent removal. These preliminary results can
have a relevant impact in the sports setting, both
recreational and competitive.

International Journal of Human Movement and Sports Sciences 8(2): 63-68, 2020 67
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