up, massage, and

stretching on range of motion and muscle

strength in the lower extremity
Effects of

warming
MARGARETA

WIKTORSSON-MOLLER,*†
JAN

From the

EKSTRAND,‡

ÖBERG,†RPT,

GILLQUIST,‡

MD

Departments of †Physiotherapy and ‡ Orthopaedic Surgery, University Hospital,

Linkoping, Sweden
players.3

In order to increase their flexibility, various techhave been used by Swedish soccer teams. Muscle
massage and different stretching exercises are included in
programs. The effectiveness of these techniques does not,
however, seem to be established. Before performing a largescale field test over a long period of time, we wished to
compare some forms of flexibility treatment in a laboratory
experiment. The goal was to study the effect on ROM and
muscle strength in the lower extremity.

ABSTRACT

niques

The effects of general warming up, massage, and

stretching on ranges of motion (ROM) and strength of
quadriceps and hamstring muscles were measured in
eight male volunteers. Thigh muscle strength was not
influenced by the experimental procedures. Stretching
resulted in a significantly increased range of hip flexion/
extension, hip abduction, knee flexion, and ankle dorsiflexion; the effect was significantly greater than that
obtained by massage and warming up separately or
combined. Only ankle dorsiflexion was influenced by
massage or warming up, whereas stretching affected
all muscle groups tested. Stretching was, therefore,
superior to the other methods tested for increasing
flexibility in the lower extremity.

MATERIALS AND METHODS

Eight healthy male volunteers with no history of musculoskeletal or neurologic problems were examined. All participated in moderate physical fitness programs, but were not
soccer players.
Six ROMs of the lower extremity (hip flexion, hip extension, hip abduction, knee flexion, ankle dorsiflexion with
knee straight and flexed) were measured immediately before
and after the experimental procedure. Hip abduction was
measured with a specially constructed double protractor
goniometer, and the other movements were measured with
a flexometer.5 The coefficient of variation for goniometric

It is estimated that in Europe soccer is responsible for 50 to

60% of all sports injuries. Of all injuries treated in the
6
hospital, 3.5 to 10% are due to soccer.~
In 1970, the estimated cost to Swedish society from the
injuries incurred due to the four major ball sports (soccer,
handball, bandy, and ice hockey) was 25 million crowns.~7
This figure includes loss of working days. Injuries are especially frequent in the lower extremity.3,1O
It has been shown that the design of training has an
important effect on the type and number of injuries, and
that many injuries can be avoided by a change in training

measurements

was

1.9 0.7%.

Hamstrings and quadriceps strength was measured immediately after each measurement of ROM with Cybex-II
isokinetic dynamometer (Lumex, Bay Shore, NY) equipped
with an x-y pen recorder (Bryants 50,000). The strength was
measured at angular velocities of 30 and 180/sec. Isometric

methods.4

measurements were made with the knee in 60 flexion. The

best of three trials was used.
General warming up was done on a bicycle ergometer with
a load of 50 W for 15 minutes to simulate the warming-up
time common on the soccer field.
Massage is a special form of muscle treatment intended
to relax tense muscles. It consists of a kneading motion over

Muscle tightness seems to predispose to certain injuries.

Soccer players are less flexible than a group of nonsoccer

Address correspondence and requests for repnnts to Mrs Margareta

Wiktorsson-Moller, University Hospital, Department of Physiotherapy, S-581,
85

BIRGITTA

MD, AND JAN

Linkoping, Sweden
249

250

the affected muscles. The subjects generally experience a

feeling of relaxation and comfort. In this study, massage was
given by a professional masseur with special training in
muscle treatment. He was involved in the training programs
of many local and national soccer teams. Massage was given
to all major muscles of the leg. The masseur varied the time
of 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 contraction, followed by relaxation and a passive extension of
the muscle. Starting from maximal, passive extension of the
muscle or muscle group, the subject made a maximal isometric contraction (A) lasting 4 to 6 seconds. This was
followed by full relaxation (B) lasting at least 2 seconds.
Passive extension (C) involves a second passive joint
movement as great as possible without causing pain, maintained for 8 seconds at the maximally extended position.
The cycle A to C is repeated five to six times for each muscle
or muscle group. The whole stretching program for all six
muscle groups took 15 minutes.
The experiments were performed in four sessions with 48
hours rest between the sessions in order to avoid any residual
effect from the preceding experiment. Each experiment consisted of measurement of ROM and Cybex testing before
and 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 18C. No food was taken for at least
4 hours before tests, and no hard exercise was allowed
between experiments.

given as mean SEM. Differences betested with Students t-test and individual
differences before and after the experimental procedures
with Students paired t-tests
The results

tween

are

means were

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

Warming

up

A significant increase (P < 0.02) in ROM was noted for

ankle dorsiflexion with the knee straight (17%) and flexed
(15%). There was no effect on the other goniometric measurements.

2. Change in ROM in degrees in three muscle groups

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

Figure

Figure

1.

Experimental design.

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.

251

TABLE 2

Hamstrmg strength before and after different experimental proceduresa

a Mean values are in Newtonmeters SEM.

b
Differences significant at the 5% level.
Differences significant at the 2% level.
c

TABLE 3

Quadriceps strength 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 and
straight was significantly increased by 10 to 12% (P < 0.005).

Warming up and massage

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

Warming

up and

This resulted in

stretching

significant increase in ROM for all muscle

groups
Fig. 2). It also showed the greatest
increase of all experimental procedures in percent compared
(Table

1 and

to the initial value. Ankle dorsiflexion with the knee flexed

increased by 31% (P < 0.001). Hip extension however increased by only 3% (P < 0.02).
Muscle

strength

After massage alone, decrease in strength was noted in the

hamstrings when recording at angular velocities of 180
(P < 0.02) and 30/sec (P < 0.05), and in the quadriceps
isometric recording (P < 0.05) (Tables 2 and 3). Neither
stretching nor warming up had any effect on muscle

as giving more exact measurements of muscle strength than

previous methods.9
Massage and warming up, separately or in combination,
gave no increase in ROM except on triceps surae, which
seems to be a readily influenced muscle group. Warming up
on a bicycle ergometer results in a contraction/relaxation
cycle for this muscle which probably explains the effect
recorded, since massage and warming up in combination did
not increase ROM significantly more than did warming up
alone. However, the effect of massage alone might be explained by manual passive elongation of the muscle.
Stretching gave significant increase in all six ROMs. It
was only tested after general warming up since this combination is the recommended procedure from the National
Sports Association of Sweden. From a purely scientific
standpoint, it might have been interesting to test stretching
alone, but this is not the way it would be used on the soccer
field. Furthermore, the effect of stretching was far greater
than the effect of warming up which only affected one muscle
group. It thus seems unlikely that the warming up procedure
contributed to any significant degree to the results of
stretching. Stretching, therefore, seems to be a better way
to increase flexibility. It can be performed by the player
himself without expensive equipment. The effect of increased flexibility on the incidence of soccer injuries remains

to be studied.

strength.
REFERENCES

DISCUSSION
1

We have been unable to find any previous studies on the

effects of stretching, massage, and warming up on flexibility
in the lower extremity.
deVries refers to investigations in which massage, running
in place, and isometric stretching gave significant improvement in muscle strength.2 Using the Cybex II, we recorded
a significant fall in strength after massage, but no effect
after the other procedure. The Cybex II is generally regarded

2
3
4

P Statistical Methods in Medical Research Oxford, Blackwell

Scientific Publications, 1974
deVries H Physiology of Exercise for Physical Education and Athletics
Second Edition, Dubuque, W C Braun, 1980, pp 451-453
Ekstrand J, Gillquist J The frequency of muscle tightness and injuries in
soccer players Am J Sports Med 10 75-78, 1982
Ekstrand J, Gillquist J, Liljedahl S-O Prevention of soccer injuries Supervision by doctor and physiotherapists Am J Sports Med 11 116-120,
1983
Ekstrand J, Wiktorsson M, Oberg B, et al: Lower extremity goniometric
measurements A study to determine their reliability Arch Phys Med
Rehabil 63 171-175, 1982

Armitage

252
6 Franke K Traumatologie des Sports Berlin, VEB Verlag, Volk und Gesundheit, 1977
7 Idrottsskador Olycksfallsriskeni bandy, fotboll, handbol och ishockey
Folksams Halsorads Skriftsene H S 10, Stockholm, 1970
8 Jungwirth K, Myrenberg M Studier av behandlingstekniken "Contract-

Relaxi PNF, Sjukgymnasten 11 1-6, 1973

Moffroid M, Whipple R, Hofkosh J, et al A study of isokinetic exercise
Phys Ther 7 735-746, 1969
10 Pardon ET Lower extremities are site of most soccer injuries Physician
Sports med 6 43-48, 1977
9