Hamstring Tissue Flossing vs Suboccipital Muscle Inhibition in Football Players

Short hamstring syndrome is characterized by reduced hamstring flexibility and tightness, which may affect lower-extremity movement and function in physically active individuals such as football players. This study is designed to compare two physiotherapy approaches: hamstring tissue flossing and suboccipital muscle inhibition technique.

The study will use a randomized clinical trial design. Participants will be recruited from Athar Football Academy (AFA), Lahore, using a non-probability convenience sampling technique. A total sample of 72 football players is planned, with 36 participants allocated to each group after accounting for a 10% attrition rate. Participants will be male or female football players aged 18 to 35 years who have unilateral hamstring tightness, defined in the protocol by a straight leg raise of less than 80 degrees and an active knee extension of less than 125 degrees. Participants will also have a BMI between 18.5 and 29.9 kg/m² and practice football at least three days per week.

Participants with acute or chronic hamstring strain or lower back pain, a lower-extremity injury within the previous three months, leg length discrepancy, sedentary lifestyle, or upper or lower motor neuron lesions will be excluded. Participants who are unwilling to provide informed consent will also be excluded.

Eligible participants will be randomly allocated using a sealed-envelope method. The study will use single blinding, with the outcome assessor blinded to group allocation.

Group A will receive hamstring tissue flossing in addition to conventional physiotherapy. Conventional physiotherapy will include hot pack application, TENS, hamstring stretching, and ankle pump exercises. Hamstring tissue flossing will then be applied using a flossing band around the thigh. The protocol specifies application of the flossing band for approximately 1 to 3 minutes, with compression assessed using a sphygmomanometer. Participants in this group will receive 30-minute intervention sessions four times per week for five weeks.

Group B will receive suboccipital muscle inhibition technique in addition to the same conventional physiotherapy. The suboccipital technique will be performed with the participant in a supine position while the therapist applies gentle pressure beneath the occipital region for approximately two minutes until tissue relaxation is achieved. Participants in this group will also receive 30-minute intervention sessions four times per week for five weeks.

Outcome assessment will include quality of life, lower-extremity function, range of motion, and hamstring tightness. Quality of life will be assessed using the SF-12 Health Survey. Lower-extremity function will be assessed using the Lower Extremity Functional Scale (LEFS). Range of motion will be assessed using the Active Knee Extension test with a universal goniometer. Hamstring tightness will be assessed using the popliteal angle.

The study hypothesis is that there will be a significant difference between hamstring tissue flossing and suboccipital muscle inhibition technique in their effects on quality of life, range of motion, lower-extremity function, and hamstring tightness in football players with short hamstring syndrome.

Data will be analyzed using IBM SPSS Statistics version 27.0. Normality will be assessed using the Kolmogorov-Smirnov test. Paired t-test or Wilcoxon Signed-Rank Test will be used for within-group comparisons, while Independent t-test or Mann-Whitney U Test will be used for between-group comparisons, according to data distribution.

• Hamstring Tissue Flossing (Behavioral): Hamstring tissue flossing will be applied using an elastic flossing band around the thigh. The protocol specifies application for approximately 1 to 3 minutes, with compression assessed using a sphygmomanometer. The flossing procedure will be performed following conventional physiotherapy.
• Conventional Physiotherapy (Behavioral): Conventional physiotherapy will consist of hot pack application for 5 minutes, TENS for 10 minutes, passive hamstring stretching, and ankle pump exercises.
• Suboccipital Muscle Inhibition Technique (Behavioral): The participant will lie in a supine position with the eyes closed. The therapist will place the palms beneath the participant's head and use the middle and ring fingers to locate the area between the occipital condyles and the spinous process of the second cervical vertebra. Gentle upward pressure will be applied toward the patient's nose and in the direction of the head for approximately 2 minutes until tissue relaxation is achieved.
• Conventional Physiotherapy (Behavioral): Conventional physiotherapy will consist of hot pack application, TENS, hamstring stretching, and ankle pump exercises, following the same routine as Group A.

Primary outcomes

• Active Knee Extension (AKE) Test [Baseline and after 5 weeks of intervention]: Hamstring flexibility/range of motion will be assessed using the Active Knee Extension test with a universal goniometer.

Secondary outcomes

• Quality of Life (SF-12) [Baseline and after 5 weeks of intervention]: Quality of life will be assessed using the 12-item Short Form Health Survey (SF-12).
• Lower Extremity Function [Baseline and after 5 weeks of intervention]: Lower-extremity function will be assessed using the Lower Extremity Functional Scale (LEFS), a 20-item patient-reported measure with a total score ranging from 0 to 80.
• Hamstring Tightness [Baseline and after 5 weeks of intervention]: Hamstring tightness will be assessed using the popliteal angle measured with a universal goniometer.

Sex: All, ages: 18 Years to 35 Years

Inclusion Criteria:

Football players aged 18 to 35 years. Both male and female players. Players with unilateral hamstring tightness with Straight Leg Raise (SLR) less than 80° and Active Knee Extension (AKE) less than 125°.

Players with a BMI between 18.5 kg/m² and 29.9 kg/m². Players who practice football at least 3 days per week.

Exclusion Criteria:

Players with any acute or chronic hamstring strain or lower back pain. Players with a previous history of lower-extremity injury within the past 3 months.

Players who are not willing to provide informed consent. Players with leg length discrepancy. Players with a sedentary lifestyle. Players with an upper motor neuron or lower motor neuron lesion.