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Effects of warming up, massage, andstretching on range of motion and musclestrength in the lower extremity

MARGARETA WIKTORSSON-MOLLER,*†BIRGITTA ÖBERG,&dagJAN EKSTRAND,‡MD, AND JAN GILLQUIST,‡MD

From the Departments of †Physiotherapyand ‡ OrthopaedicSurgery, University Hospital,Linkoping, Sweden

ABSTRACT

The effects of general warming up, massage, andstretching on ranges of motion (ROM) and strength ofquadriceps and hamstring muscles were measured ineight male volunteers. Thigh muscle strength was notinfluenced by the experimental procedures. Stretchingresulted in a significantly increased range of hip flexion/extension, hip abduction, knee flexion, and ankle dor-siflexion; the effect was significantlygreater than thatobtained by massage and warming up separately orcombined. Only ankle dorsiflexion was influenced bymassage or warming up, whereas stretching affectedall muscle groups tested. Stretchingwas, therefore,superior to the other methods tested for increasingflexibility in the lower extremity.

It is estimated that in Europe soccer is responsible for 50 to60% of all sports injuries. Of all injuries treated in thehospital, 3.5 to 10% are due to soccer.~6

In 1970, the estimated cost to Swedish society from theinjuries incurred due to the four major ball sports (soccer,handball, bandy, and ice hockey) was 25 million crowns.~ 7This figure includes loss of working days. Injuries are espe-

cially frequent in the lower extremity.3,1OIt has been shown that the design of training has animportant effect on the type and number of injuries, andthat many injuries can be avoided by a change in trainingmethods.4

Muscle tightness seems to predispose to certain injuries.Soccer players are less flexible than a group of nonsoccer

players.3In order to increase their flexibility, various tech-niques have been used by Swedish soccer teams. Musclemassage and different stretching exercises are included inprograms. The effectiveness of these techniques does not,however, seem to be established. Before performing a large-scale field test over a long period of time, we wished tocompare some forms of flexibility treatment in a laboratoryexperiment. The goal was to study the effect on ROM andmuscle strength in the lower extremity.

MATERIALS AND METHODS

Eight healthy male volunteers with no history of musculo-skeletal or neurologic problems were examined. All partici-pated in moderate physical fitness programs, but were notsoccer players.

Six ROMs of the lower extremity (hip flexion, hip exten-sion, hip abduction, knee flexion, ankle dorsiflexion withknee straight and flexed) were measured immediately beforeand after the experimental procedure. Hip abduction wasmeasured with a specially constructed double protractorgoniometer, and the other movements were measured witha flexometer.5 The coefficient of variation for goniometricmeasurements was 1.9 ± 0.7%.

Hamstrings and quadriceps strength was measured im-mediately after each measurement of ROM with Cybex-IIisokinetic dynamometer (Lumex, Bay Shore, NY)’ equippedwith an x-y pen recorder (Bryants 50,000). The strength wasmeasured at angular velocities of 30 and 180°/sec. Isometricmeasurements were made with the knee in 60° flexion. Thebest of three trials was used.

General warming up was done on a bicycleergometer witha load of 50 W for 15 minutes to simulate the warming-uptime common on the soccer field.

Massage is a special form of muscle treatment intendedto relax tense muscles. It consists of a kneading motion over

’ Address correspondence and requests for repnnts to Mrs MargaretaWiktorsson-Moller, University Hospital,Department of Physiotherapy, S-581,85 Linkoping, Sweden

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the affected muscles. The subjects generally experience afeeling of relaxation and comfort. In this study, massage wasgiven by a professional masseur with special training inmuscle treatment. He was involved in the training programsof many local and national soccer teams. Massage was givento all major muscles of the leg. The masseur varied the timeof the massage between 6 and 15 minutes (X 12 minutes)depending on how tense he felt the muscles to be.

The stretching procedure consisted of an isometric con-traction, followed by relaxation and a passive extension ofthe muscle. Starting from maximal, passive extension of themuscle or muscle group, the subject made a maximal iso-metric contraction (A) lasting 4 to 6 seconds. This wasfollowed by full relaxation (B) lasting at least 2 seconds.’

Passive extension (C) involves a second passive jointmovement as great as possible without causing pain, main-tained for 8 seconds at the maximally extended position.The cycle A to C is repeated five to six times for each muscleor muscle group. The whole stretching program for all sixmuscle groups took 15 minutes.

The experiments were performed in four sessions with 48hours rest between the sessions in order to avoid any residualeffect from the preceding experiment. Each experiment con-sisted of measurement of ROM and Cybex testing beforeand after the experimental procedure to be tested (Fig. 1).The experiments were done in the following order:

. general warming up

. general warming up and massage

. massage alone

. general warming up and stretching.The experiments were conducted between 5 and 8 PM at

a room temperature of 18°C. No food was taken for at least4 hours before tests, and no hard exercise was allowedbetween experiments.

Figure 1. Experimentaldesign.

The results are given as mean ± SEM. Differences be-tween means were tested with Student’s t-test and individualdifferences before and after the experimental procedureswith Student’s paired t-tests

RESULTS

The results of goniometry are shown in Table 1 and Fig. 2.No difference could be found between the left and rightsides. For each movement the average of left and right wasused to represent the ROM.

Warming up

A significant increase (P < 0.02) in ROM was noted forankle dorsiflexion with the knee straight (17%) and flexed(15%). There was no effect on the other goniometric meas-urements.

Figure 2. Change in ROM in degrees in three muscle groupsafter treatment. Add = adductors (hip abduction); ham =

hamstrings (hip flexion); Rec = rectus femons (knee flexion).Solid line = initial value; - - - = value obtained after generalwarming up and stretching. For adductors and hamstrings,the values after massage, general warming up, and generalwarming up plus massage were the same as the initial value.For rectus femons, general warming up plus massage re-sulted in a slight increase (dotted line).

TABLE 1

Change in ROM in eight subjects after different forms of muscle treatment compared to the initial valuea

° Mean values are shown in percent ± SEM.

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TABLE 2

Hamstrmg strength before and after different experimental proceduresa

a Mean values are in Newtonmeters ± SEM.b Differences significant at the 5% level.c Differences significant at the 2% level.

TABLE 3

Quadricepsstrength before and after different experimental proceduresa

a Mean values are in Newtonmeters ± SEM.b Differences significant at the 5% level.

Massage

Only ROM for ankle dorsiflexion with the knee bent andstraight was significantly increased by 10 to 12% (P < 0.005).

Warming up and massage

An increase was noted for ankle dorsiflexion both with theknee flexed (14%) and straight (15%) (P < 0.002-0.005). Adecrease was noted for hip extension with 4.5% (P < 0.05).

Warming up and stretching

This resulted in asignificant

increase in ROM for all muscle

groups (Table 1 and Fig. 2). It also showed the greatestincrease of all experimental procedures in percent comparedto the initial value. Ankle dorsiflexion with the knee flexedincreased by 31% (P < 0.001). Hip extension however in-creased by only 3% (P < 0.02).

Muscle strength

After massage alone, decrease in strength was noted in thehamstrings when recording at angular velocities of 180(P < 0.02) and 30°/sec (P < 0.05), and in the quadricepsisometric recording (P < 0.05) (Tables 2 and 3). Neitherstretching nor warming up had any effect on muscle

strength.

DISCUSSION

We have been unable to find any previous studies on theeffects of stretching, massage, and warming up on flexibilityin the lower extremity.

deVries refers to investigations in which massage, runningin place, and isometric stretching gave significant improve-ment in muscle strength.2Using the Cybex II, we recordeda significant fall in strength after massage, but no effectafter the other procedure. The Cybex II is generally regarded

as giving more exact measurements of muscle strength thanprevious methods.9

Massage and warming up, separately or in combination,gave no increase in ROM except on triceps surae, whichseems to be a readily influenced muscle group. Warming upon a bicycle ergometer results in a contraction/relaxationcycle for this muscle which probably explains the effectrecorded, since massage and warming up in combination didnot increase ROM significantly more than did warming upalone. However, the effect of massage alone might be ex-plained by manual passive elongation of the muscle.

Stretching gave significant increase in all six ROMs. Itwas

onlytested after

general warming upsince this combi-

nation is the recommended procedure from the NationalSports Association of Sweden. From a purely scientificstandpoint, it might have been interesting to test stretchingalone, but this is not the way it would be used on the soccerfield. Furthermore, the effect of stretching was far greaterthan the effect of warming up which only affected one musclegroup. It thus seems unlikely that the warming up procedurecontributed to any significant degree to the results ofstretching. Stretching, therefore, seems to be a better wayto increase flexibility. It can be performed by the playerhimself without expensive equipment. The effect of in-creased flexibility on the incidence of soccer injuries remainsto be studied.

REFERENCES

1 Armitage P Statistical Methods in Medical Research Oxford, BlackwellScientific Publications, 1974

2 deVries H Physiology of Exercise for Physical Education and AthleticsSecond Edition, Dubuque, W C Braun, 1980, pp 451-453

3 Ekstrand J, GillquistJ The frequency of muscle tightness and injuries insoccer players Am J Sports Med 10 75-78, 1982

4 Ekstrand J, Gillquist J, Liljedahl S-O Prevention of soccer injuries Super-vision by doctor and physiotherapists Am J Sports Med 11 116-120,1983

5 Ekstrand J, Wiktorsson M, Oberg B, et al: Lower extremity goniometricmeasurements A study to determine their reliability Arch Phys MedRehabil 63 171-175, 1982

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6 Franke K Traumatologie des Sports Berlin, VEB Verlag,Volk und Gesun-dheit, 1977

7 Idrottsskador Olycksfallsrisken i bandy, fotboll, handbol och ishockeyFolksams Halsorads Skriftsene H S 10, Stockholm, 1970

8 Jungwirth K, Myrenberg M Studier av behandlingstekniken "Contract-

Relax’ i PNF, Sjukgymnasten 11 1-6, 19739 Moffroid M, Whipple R, Hofkosh J, et al A study of isokinetic exercise

Phys Ther 7 735-746, 196910 Pardon ET Lower extremities are site of most soccer injuries Physician

Sports med 6 43-48, 1977