Foam rolling’s effect on athletic performance and injury risk reduction

By: Abraham Campbell

Foam rolling (FR) has become a popular exercise “recovery tool” used by athletes in recent years. It has also been proposed that FR can improve athletic performance and reduce injury (Wiewelhove et al., 2019).  Advocates claim FR alleviates muscle soreness, reduces joint stress, improves; range of motion, muscular imbalances, and neuromuscular efficiency (Macdonald et al., 2014). However, there is little consensus on FR protocols, effectiveness, or physiological mechanisms (Hendricks et al., 2020; Wiewelhove et al., 2019). Therefore, the purpose of this review is to evaluate and summarize the relevant literature on the effectiveness of FR on athletic performance and injury risk reduction. Secondly, based upon the evidence FR protocols (pre- vs. post- exercise, duration, and frequency) and physiological mechanisms will be discussed to highlight clinically relevant recommendations for patients, athletes, and clinicians.

Wiewelhove et al., (2019) meta-analysis examined the effect of FR on performance and recovery in athletic populations. The authors were interested in comparing the effects of “pre-rolling” as warm-up activity and “post-rolling” as a recovery strategy. The researchers analyzed outcomes of FR’s effect on sprint, jump, strength, flexibility, and muscle pain perception. A total of 21 studies were examined; 14 used the “pre-rolling” before exercise and 7 used “post-rolling” after exercise. A total of 454 participants were included in the study. In total (n=306) used FR as a warm-up strategy while (n=148) used FR post-exercise for recovery (n=148). An overall summary of the body of literature in “pre-rolling” resulted in small improvements in sprint performance (+0.7%, g = 0.28) and flexibility (+4.0%, g = 0.34). The effect on strength (+1.8%, g = 0.12) and jump performance (−1.9%, g = 0.09) was insignificant. FR “pre-rolling” resulted in a 1.5% overall weighted average of performance change. “Post-rolling” mitigated reductions in sprint (+3.1%, g = 0.34) and strength performance (+3.9%, g = 0.21). “Post-rolling” also resulted in reduction in muscle pain perception (+6.0%, g = 0.47). However, “post-rolling’s” effect on jump performance (−0.2%, g = 0.06) was minimal. The overall weighted performance effect of post-rolling resulted in 2.0% change in performance.

Wiewelhove et al., (2019) conclude; pre-exercise FR use had the greatest effect on flexibility amongst all variables. Although, post-exercise FR induced increases in flexibility were not examined. Overall, the authors suggest that 62% of the population will experience acute improvements in flexibility using the FR pre-exercise. Furthermore, FR induced improvements in flexibility may not negatively impact muscle performance. This is of particular importance as pre-exercise static stretching (>60 sec) has been associated with reduced muscle performance (Kay et al., 2012). Additionally, improving flexibility is a key correlate to reducing injuries in the athletic populations. Athletes with inflexibilities in the extremities may have a statistically greater risk of a musculoskeletal injury (Witvrouw et al., 2003). Evidence suggests “post-rolling” is a more beneficial means of FR use, alleviating muscle soreness and promoting a more rapid recovery resulting to greater athletic performance in speed and strength (Wiewelhove et al., 2019). While pre-exercise FR leads to greater flexibility without negatively effecting muscle performance.

Hendrinks et al., (2020) systematic review of 49 studies examined the effectiveness of FR used as a “warm-up” aid to improve performance or implemented post exercise to enhance recovery. Hendriks et al., (2020) findings were similar to previous literature (Wiewelhove et al., 2019) examining FR pre- or post- exercise. Based on 26 studies examining FR use on “performance” (pre-exercise) the authors found that FR increases flexibility but resulted in no improvements in athletic performance (force and power outcomes). Hendricks et al., (2020) suggested FR can be used pre-exercise to increase flexibility but proposed it be used in combination with an active warm-up and dynamic stretching.

Hendricks et al., (2020) examined 26 studies using FR use for “recovery” (post-exercise). Five of which analyzed exercise induced muscular damage (EIMD) and delayed onset muscular soreness (DOMS). The results on post-exercise FR were similar to Wiewelhove et al., (2019).  Results suggested that FR can be an effective modality to enhance recovery by mitigating DOMS and EIMD. Thus, reducing performance decrement in between bouts of exercise. Hendricks et al., (2020) suggested the optimum use of FR for reduction in performance decrement and recovery should be for a duration of 30-60 seconds, 3-5 sets with 10-30 second rest periods. However, it was proposed that flexibility would be enhanced with longer durations of 90-120 seconds of FR use. Interestingly, FR during resistance training may have a decremental effect on a muscle’s ability to generate force. But FR less than 90 seconds showed no effect on anaerobic power.

Additionally, Hendricks et al., (2020) proposed any performance benefit elicited by FR would be neurophysiological in origin mainly from neural inhibition. This mechanism was supported by Cavanaugh et al., (2017) study where researchers found that FR use on an agonist muscle groups may alter activation of antagonistic muscle groups. Macdonald et al., (2014) study demonstrated an improvement in vertical jump performance in participants after bouts of resistance training whereas FR was used post-exercise on muscle groups of the lower extremities for 60 seconds. The researchers also cited neural inhibition as a main contributing factor to vertical jump performance. The authors proposed this was because of the accelerated recovery of connective tissue inflammation and mitochondria biogenesis (Crane et al., 2012). Decreased activation of nociceptors is thought to enhance communication to afferent receptors in the connective tissue which has been proposed to maintain muscle recruitment patterns (Saxton et al., 1995). FR has also demonstrated vascular effects such as improvements in blood flow, reduction of arterial stiffness and improvement in endothelial function (Hotfiel et al., 2017). Promotion of blood flow between bouts of exercise has been associated with enhancement of exercise recovery (Borne et al., 2017).

In a randomized control study, Ozden & Yesilyaprak (2021) investigated the effect of FR on elbow proprioception, strength, and functional motor performance during a 4-week FR intervention. Sixty participants (mean age=22.83±4.07 years) were randomized into two groups (n=30) foam rolling and a control group. Baseline and outcomes measures included a joint position test (JPS), force matching evaluation, muscle strength of the biceps brachii, and functional motor performance; CKCUEST test (Closed Kinetic Chain Upper Extremity Stabilization Test), modified pull-up test (MPUT), push-up test. Participants in the foam rolling intervention performed FR sessions 1 session a day, 3 days of the week for a duration of 4 weeks under the instruction of a physical therapist. The participants foam rolled their biceps brachii for 2 sets 60 seconds in duration with 30 second rest periods in between sets. FR showed improvement in the JPS evaluation at 45 degrees of elbow flexion, muscle strength, CKCUEST, and push-up test after the 4-week FR intervention. These improvements were also maintained for 1 month as compared to the control group. This study highlighted some important findings demonstrating FR induced strength improvements and maintenance of strength for up to four weeks.

Ozden et al., (2021) propose FR induced increases in strength are similar mechanisms of massage facilitating biogenesis of mitochondrial cells (Crane et al., 2012). Mitochondrial biogenesis was also cited by Macdonald et al., (2014) as a primary mechanism for improvement in vertical jump performance. FR induced mitochondrial biogenesis has been proposed to cause greater oxygenation of skeletal muscle and improved muscle performance (Peacock et al., 2014). Other potential FR strength mechanisms include ANS activation and mechanoreceptors such as Type III and IV receptors in the fascia that respond to touch thus reducing sympathetic tone, increases in gamma motor neuron activation and relaxation of intrafascial smooth muscle cells (Wiktorsson-Möller et al., 1983; as cited by Ozden et al., 2021). This relaxation may have a positive effect on muscle length-tension relationship resulting in an improvement in muscle performance (Freiwald., 2017 as cited by Ozden at al., 2021).

Ozden et al., (2021) propose the long-term maintenance of strength was elicited by FR pressure and contact stimulation of proprioceptors in the myofascia. This allegedly may induce myofascial awareness from mechanical and nociceptor structures within the fascia which send neural inputs to the brain resulting in “myofascial memory” (Ozden at al., 2021). However, none of these proposed mechanisms were investigated. FR improvements in flexibility (Hendricks et al., 2020; Wiewelhove et al., 2019) have been proposed to be caused by central-pain modulatory centers. FR induced constant and vigorous soft tissue pressure may have an effect on skin receptors and inhibit pain sensation, thereby increasing tolerance to stretching (Kelly et al., 2016). However, FR mechanisms remain unclear and very few studies have examined the physiological determinants (Wiewelhove et al., 2019).

FR has several applications for the athlete. FR can be a minimally time-consuming and efficient tool facilitating the physiological recovery process and improve flexibility. Its “performance” enhancement is mostly due to the reduction in EIMD, DOMS, perception of pain and enhancement of blood flow, reduction in inflammation and adhesion between layers of fascia (MacDonald et al., 2014). FR may be beneficial between heavy bouts of exercise to facilitate physiological recovery. However, some research suggests FR has direct benefit on performance (MacDonald et al., 2014 Ozden et al., 2021; Wiewelhove et al., 2019) likely neurological in origin however this remains undetermined. For the athlete wishing to improve flexibility FR use pre-exercise used in combination with an active warm-up and dynamic stretching seems to show the greatest effect (Hendricks et al., 2020; Wiewelhove et al., 2019). Enhancement of flexibility may reduce the risk of injuries (Witvrouw et al., 2003). Furthermore, evidence suggests that FR may preserve a “baseline” of muscle strength this may be beneficial to the injured athlete to supplement the rehabilitation process during immobility, restriction, or inability to train (Ozden at al., 2021). General recommendations for minimally effective dose of post-exercise FR use is; 30-60 seconds, 2-5 sets ranging from 1-3 days a week with brief rest periods in between 10-30 seconds. Similar protocols can be used for improvement in flexibility pre-exercise, but FR is recommended to be used in conjunction with an active warm-up and at a longer duration 90-120 seconds. However, specific optimal protocols have yet to be determined.

Limitations of Wiewelhove et al., (2019) and Hendricks et al., (2020) combined analysis of 70 studies examining FR make it difficult to draw comparisons or conclusions due to the variability in “exercise” (Frequency, intensity, time, and type). Some of the research also coupled “roll or massage sticks” in with FR use. Many of the studies were also of poor design (Wiewelhove et al., 2019; Hendricks et al., 2020). Future directions should use randomized control trials to better evaluate FR. RCTs being a “gold standard” in evaluating effectiveness of interventions (Akobeng, 2005). Additionally, research should evaluate the physiological mechanisms of FR use. This makes optimal FR application difficult. It is unlikely that FR effects pre- and post- exercise are mutually exclusive. Further research will allow clinicians and athletes to better apply FR to a variety of relevant applications and to determine optimal FR protocols. In conclusion, FR use is warranted in athletic populations for both performance and injury risk reduction. Although further research is paramount.

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