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Physical Therapy in Sport xxx (2012) 1e7

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Physical Therapy in Sport

journal homepage: www.elsevier .com/ptsp

Original research

Effects of a neurodynamic sliding technique on hamstring flexibility in healthymale soccer players. A pilot study

Yolanda Castellote-Caballero a, Marie Carmen Valenza b, Lydia Martín-Martín b, Irene Cabrera-Martos b,Emilio J. Puentedura c,*, César Fernández-de-las-Peñas d

aHospital Virgen de las Nieves, Servicio Andaluz de Salud, SpainbDepartment of Physical Therapy, Universidad de Granada, Granada, SpaincDepartment of Physical Therapy, School of Allied Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USAdDepartment of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain

a r t i c l e i n f o

Article history:Received 1 September 2011Received in revised form1 July 2012Accepted 11 July 2012

Keywords:HumansMuscleSkeletal/physiologyNeurodynamicShort hamstring syndromeStraight leg raise testRange of motion

* Corresponding author. University of Nevada Las VSciences, Department of Physical Therapy, 4505 MarylVegas, NV 89154-3029, USA.

E-mail address: louie.puentedura@unlv.edu (E.J. Pu

1466-853X/$ e see front matter � 2012 Elsevier Ltd.http://dx.doi.org/10.1016/j.ptsp.2012.07.004

Please cite this article in press as: Castellote-male soccer players. A pilot study, Physical T

a b s t r a c t

Purpose: To compare the short-term effects of a neurodynamic sliding technique versus control conditionon hamstring flexibility in healthy, asymptomatic male soccer players.Subjects: Twenty-eight young male soccer players from Palencia, Spain (mean age 20.7 yrs � 1.0, range19e22) with decreased hamstring muscle flexibility.Methods: Subjects were randomly assigned to one of two groups: neurodynamic sliding intervention orno intervention control. Each subject’s dominant leg was measured for straight leg raise (SLR) range ofmotion (ROM) pre- and post-intervention. Subjects received interventions as per group allocation overa 1 week period. Data were analyzed with a 2 (intervention: neurodynamic and control) � 2 (time: preand post) factorial ANOVA with repeated measures and appropriate post-hoc analyses.Results: A significant interaction was observed between intervention and time for hamstring extensi-bility, F(1,26) ¼ 159.187, p < .0005. There was no difference between the groups at the start, p ¼ .743;however, at the end of the study, the groups were significantly different with more range of motion inthe group that received neurodynamic interventions, p ¼ .001. The group that received neurodynamicinterventions improved significantly over time (p < .001), whereas the control group did not (p ¼ .684).Conclusion: Findings suggest that a neurodynamic sliding technique can increase hamstring flexibility inhealthy, male soccer players.

� 2012 Elsevier Ltd. All rights reserved.

1. Introduction

Hamstring injuries are common in physically active people andathletes participating in competitive sports such as sprinting,rugby, football, and soccer (Bahr & Holme, 2003; Davis, Ashby,McCale, McQuain, & Wine, 2005; Decoster, Cleland, Altieri, &Russell, 2005; Malliaropoulos, Papalexandris, Papalada, &Papacostas, 2004). Hamstring strains accounted for 11% of injuriesin British professional soccer and for 12.7% in the two highestsoccer divisions in Iceland (Arnason, Sigurdsson, Gudmundsson,Holme, Engebretsen, & Bahr, 2004; Dadebo, White, & George,2004). Many predisposing factors for hamstring injury have been

egas, School of Allied Healthand Parkway, Box 453029, Las

entedura).

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Caballero, Y., et al., Effects ofherapy in Sport (2012), http:

suggested within the literature, including: insufficient warm-up(Safran, Garrett, Seaber, Glisson, & Ribbeck, 1988); poor flexibility(Witvrouw, Danneels, Asselman, D’Have, & Cambier, 2003); muscleimbalance (Croisier, 2004; Croisier, Forthomme, Namurois,Vanderthommen, & Crielaard, 2002); neural tension (Turl &George, 1998); and previous injuries (Bennell et al., 1998; Verrall,Slavotinek, Barnes, Fon, & Spriggins, 2001). Among risk factors forhamstring injury, inadequate extensibility within the posteriorthigh compartment appears to be one of the more commonlyaccepted causes (Davis et al., 2005; Decoster, Scanlon, Horn, &Cleland, 2004) and it has been suggested that stretching beforephysical activity may increase extensibility of the stretched muscle,fascia and neural tissues, whichmay in turn decrease the chance forinjury (Halbertsma, Mulder, Goeken, & Eisma, 1999; Hartig &Henderson, 1999; Ross, 1999).

Hamstring stretching is considered an appropriate interventionin both the prevention and treatment of hamstring injury. Althoughstretching for the prevention of injury is common practice in many

a neurodynamic sliding technique on hamstring flexibility in healthy//dx.doi.org/10.1016/j.ptsp.2012.07.004

Fig. 1. Measurement of hamstring flexibility pre- and post-intervention using thepassive straight leg raise (SLR) test with universal goniometer.

Y. Castellote-Caballero et al. / Physical Therapy in Sport xxx (2012) 1e72

sports (Witvrouw, Mahieu, Danneels, & McNair, 2004), evidence fordecreased hamstring flexibility as a risk factor for hamstring injuryremains equivocal (Hennessey & Watson, 1993; Witvrouw et al.,2003) and a recent Cochrane review found no evidence forstretching as a sole intervention for prevention of hamstring injury(Goldman & Jones, 2010). Accordingly, flexibility has been sug-gested as but one factor in the multi-factorial etiology of hamstringstrain injury (Worrell & Perrin, 1992). In a review on risk factors forrecurrent hamstring strains, Croisier (2004) noted only limitedevidence for stretching but suggested at least normalizinghamstring length. In a Cochrane review, Mason, Dickens, and Vail(2007) reported evidence for a higher frequency of daily stretch-ing in the rehabilitation of hamstring injuries, and in another study,Witvrouw et al. (2004) suggested that stretching might be mostrelevant for sports that predominantly include plyometricactivities.

Although there are various theories, evidence is lacking for anycredible explanation for the observed increases in muscle exten-sibility following intermittent stretching. In a recent review article,Weppler and Magnusson (2010) suggested that increases in tissueextensibility come not from affecting the mechanical properties ofthe muscle being stretched but result from changes in the indi-vidual’s perception of stretch or pain. In other words, the point oflimitation in hamstring range is increased not because of changeswithin the muscle structure but rather, because the individualreceiving the stretching interventions has adopted a ‘new stoppoint’ for limitation in hamstring range based on altered percep-tions of stretch or pain. This is known as the ‘sensory theory’ and itproposes that increases in muscle extensibility after stretching aredue to modified sensation (Weppler & Magnusson, 2010). Changesin neurodynamics (movement of the nervous system) could modifysuch sensations. Neurodynamics is the term used to describe theintegration of the morphology, biomechanics and physiology of thenervous system (Butler, 2000; Shacklock, 2005).

An individual with decreased hamstring extensibility maydemonstrate limited range in the passive straight leg raise test(SLR) because of altered neurodynamics affecting the sciatic, tibialand common fibular nerves (Kornberg & Lew, 1989). Abnormalposterior lower extremity neurodynamics may influence restingmuscle length and lead to changes in the perception of stretch orpain (Marshall, Cashman, & Cheema, 2011). It follows thatproviding a movement/stretching intervention could alter theneurodynamics and lead to modification of the sensation andultimately, increased extensibility.

The purpose of the current paper, therefore, is to explore theeffect of a specific neurodynamic intervention on passive SLR inhealthy soccer players, and specifically investigate the hypothesisthat neurodynamic mobilizations (sliders) would produce a greateripsilateral increase in SLR than control treatment.

2. Methods and materials

2.1. Subjects

We recruited a convenience sample of 28 subjects (all male;mean age 20.8 � 1.0, range 19e22) who were active in the Palencianon-professional soccer leagues. Subjects had to be aged between18 and 25 years, and actively participating in soccer (training andcompetitive matches) for at least 5 h/week and at least 3 days/week. Exclusion criteria were as follows: a) any hamstring injurywithin the past year; b) presence of any history of neurological ororthopedic disorder affecting the lower extremities (e.g. peripheralneuropathy, femoral fracture, meniscal injury, low back pain, etc.);and/or c) exceeding 75� in the initial passive SLR. Subjects signeda consent form and agreed to participate in two testing sessions

Please cite this article in press as: Castellote-Caballero, Y., et al., Effects ofmale soccer players. A pilot study, Physical Therapy in Sport (2012), http:

separated by one week. Recruitment occurred between April andJuly 2010. This study received ethical approval from the EthicalCommittee of the University of Granada, Spain.

2.2. Measurement of hamstring flexibility

All physical measurements were obtained by the same pair oftrained evaluators who were blinded to each subject’s group allo-cation and included height and weight to determine body massindex (BMI ¼ kg/m2). The passive SLR test was used to determinechanges in hamstring muscle extensibility. With the subject in thesupine position, the lateral condyle of the femur was pinpointedwith a marker, as were the head of the fibula and the fibular mal-leolus. The axis of a goniometer was placed on the projection of thegreater trochanter of the femur. One of the arms of the goniometerwas placed parallel to the table (checking with a level). The kneeand ankle were kept in the extension position. Holding the talusand without rotating the hip, flexion of the hip was graduallyincreased, lifting the subjects’ lower limb until they first com-plained of pain in the region of the posterior thigh. The point of firstonset of pain has traditionally been referred to as P1 (Maitland,Hengeveld, Banks, & English, 2005). Care was taken to ensurethat they did not bend their knee, or begin to swing the pelvis inretroversion. At that moment, the other arm of the goniometer wasplaced in the direction of the line between the head of the fibulaand the fibularmalleolus, and the degree of elevation of the straightleg was noted. One evaluator was tasked with performing thepassive SLR to P1, while the other was tasked with taking thegoniometric measurement (Fig. 1). This measurement has beenshown to have high reliability and validity in various studies. Boyd(2012) reported intra-rater reliability ICCs to be 0.95e0.98; thestandard error of measurement (SEM) was between 0.54� and1.22�; and minimal detectable change was between 1.50� and 3.41�.Walsh and Hall (2009) found substantial agreement between SLRand slump test interpretation (kappa ¼ 0.69) and good correlationin ROMbetween the two tests (r¼ 0.64). Measurements were takenbefore the intervention and re-evaluated after the intervention(moving to end of ROM). Between-session intra-rater reliabilitywas established on the first 10 subjects as sufficient for clinicalmeasurement (ICC ¼ .91).

2.3. Procedures

All subjects began with a single measure of the passive SLR ontheir dominant (kicking) leg. As long as range of motion was �75�,

a neurodynamic sliding technique on hamstring flexibility in healthy//dx.doi.org/10.1016/j.ptsp.2012.07.004

Y. Castellote-Caballero et al. / Physical Therapy in Sport xxx (2012) 1e7 3

they were accepted into the study. We chose to limit passive SLRrange of motion to ensure we would have subjects with bilateralshort hamstring syndrome as described by Ferrer (Ferrer, 1998;Ferrer, Santonja, Carrion, & Martinez, 1994; Verrall, Slavotinek, &Barnes, 2005). Using a random numbers table, subjects wererandomly assigned to either an intervention group or a controlgroup. Subjects in both groups were measured for passive SLR asdescribed above and the average of 3 measurements was obtainedfor each subject. Subjects in the intervention group were thentreated with neurodynamic sliding techniques on 3 different daysover 1 week, and instructed to continue their routine soccertraining sessions and matches as scheduled during the study.Subjects in the control group were given no specific treatment andinstructed to continue their routine soccer training and matches asper usual. Both groups were allowed to continue their hamstringstretching and warm-up procedures before soccer training sessions

Fig. 2. Flow chart of t

Please cite this article in press as: Castellote-Caballero, Y., et al., Effects ofmale soccer players. A pilot study, Physical Therapy in Sport (2012), http:

andmatches during the study. After 1week, subjects in both groupshad their passive SLR re-measured, with an average of 3measurements once more. The study design is shown in Fig. 2.

The neurodynamic sliding techniques administered to theintervention group consisted of ‘seated straight leg sliders’, andwere provided by a researcher blinded to SLRmeasurements. Theseneurodynamic sliders are maneuvers performed in order toproduce a sliding movement of neural structures relative to theiradjacent tissues (Butler, 2000; Mintken, Puentedura, & Louw, 2011).Sliders involve application of movement/stress to the nervoussystem proximally while releasing movement/stress distally, andthen reversing the sequence. Research has shown that slidersactually result in greater excursion than simply stretching the nerve(Coppieters & Butler, 2008). Each subject sat with their trunk inthoracic flexion (slump) and while maintaining that posture, theyperformed alternating movements of knee extension/ankle

he study design.

a neurodynamic sliding technique on hamstring flexibility in healthy//dx.doi.org/10.1016/j.ptsp.2012.07.004

Table 1Sample characteristics

Interventiongroupn ¼ 14

Control groupn ¼ 14

p Valuesa

Age (years) e mean � SD 20.79 � 1.05 20.71 � 0.99 0.792Training hours/week e mean � SD 5.23 � 1.20 5.47 � 0.84 0.607Weight (kg) e mean � SD 77.29 � 5.25 78.93 � 4.60 0.300Height (cm) e mean � SD 176.50 � 4.70 176.21 � 3.53 0.908BMI (kg/cm2) e mean � SD 24.7 � 1.35 24.5 � 1.04 0.451

a t-Test.

Y. Castellote-Caballero et al. / Physical Therapy in Sport xxx (2012) 1e74

dorsiflexion with cervical extension, and knee flexion/ankle plan-tarflexion with cervical flexion (Fig. 3). Subjects performed theseactive movements for approximately 60 s and repeated them 5times. At present, there is no research evidence on the appropriatedosage for active neurodynamic sliders; however, we chose 60 sand 5 repetitions based on clinical experience and suggestions fromauthors (Butler, 2000; Nee & Butler, 2006). Each of the subjects inthe intervention group was treated with the neurodynamic slidersfor 3 sessions on alternate days over 1 week. All interventions wereprovided by the same researcher in the training rooms at the soccerclub.

2.4. Statistical analysis

Descriptive statistics (mean, standard deviation, 95% CI) werecalculated for pre-test and post-test SLR averaged values for the 2groups. SLR responsiveness data were calculated using thebetween-session ICC established in this study (ICC ¼ .91) and theformulae SEM ¼ SD � O(1 � ICC) (Weir, 2005) andMDC95 ¼ 1.96 � O2 � SEM (Stratford, 2004). To analyze thedifference between groups over time on hamstring extensibility(SLR), one 2 (group: intervention and control) � 2 (time: pre andpost) mixed factorial ANOVA with repeated measures on bothfactors was conducted, with appropriate post-hoc analysis. Signif-icance level was set at .05. A Bonferroni corrected alpha of .0125(four t-tests) would be utilized for simple main effects (SME)analyses.

3. Results

Characteristics of the study sample are summarized in Table 1,and demonstrate that there were no significant differencesbetween the groups at the start of the study. Standard deviationsfor SLR measurements ranged from 5.9 to 7.0�. This allowed us tocalculate a range of SEM from 1.8 to 2.1� and subsequently a rangefor the MDC95 of 5.0e5.8�. The neurodynamic intervention grouphad a pre-test mean range of 58.1� (95% CI: 54.3e61.8) and post-test mean range of 67.4� (95% CI: 64.2e70.7). The control grouphad a pre-test mean range of 58.9� (95% CI: 55.2e62.7) and post-

Fig. 3. The neurodynamic sliding technique used in this study. The subject sat with their tcervical flexion and knee flexion with ankle plantarflexion (A), and then moved into cervicnating active movements were performed for approximately 60 s and repeated 5 times.

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test mean range of 59.1� (95% CI: 55.9e62.4). The pre-test-to-post-test differences in average SLR values exceeded the upperlimit of this MDC95 range for the neurodynamic intervention (9.4�)but not for the control group (0.2�).

A statistically significant interaction was observed,F(1,26) ¼ 159.187, p < .0005 (h2p ¼ :860) (Fig. 4). There was nodifference between the groups at the start, p¼ .743; however, at theend of the study, the groups were significantly different with morerange of motion in the group that received neurodynamic inter-ventions (p ¼ .001). The group that received neurodynamic inter-ventions improved significantly over time (p < .001), whereas thecontrol group did not (p ¼ .684).

4. Discussion

The results from this study showed a significant between-groupdifference favoring the neurodynamic intervention with regard toincreasing post-intervention hamstring flexibility. Furthermore,a within-group difference was observed for the intervention groupover time (p < .001) whereas no within-group difference wasobserved for the control group over time (p ¼ .684). Pre-test-to-post-test differences in average SLR values for the interventiongroup exceeded the MDC95 suggesting the changes observed werenot a result of measurement error and represent a true change inhamstring flexibility following the neurodynamic sliders.

Increasing hamstring flexibility may play an important role inpreventing lower extremity overuse injuries. In fact, a study on 298

runk in thoracic flexion (slump) and while maintaining this posture, they started withal extension while performing knee extension and ankle dorsiflexion (B). These alter-

a neurodynamic sliding technique on hamstring flexibility in healthy//dx.doi.org/10.1016/j.ptsp.2012.07.004

54

56

58

60

62

64

66

68

70

Pre PostNeurodynamic Control

p=.743

p=.001

58.9 ° 59.1°

58.1°

67.4 °

Fig. 4. Mean SLR values (�) with 95% confidence intervals of hamstring extensibility before and after intervention and control.

Y. Castellote-Caballero et al. / Physical Therapy in Sport xxx (2012) 1e7 5

military basic trainees found that the numbers of lower extremityinjuries were reduced after introduction of a hamstring stretchingregimen that significantly increased hamstring flexibility (Hartig &Henderson, 1999). Another study by Malliaropoulos et al. (2004)followed 80 Greek athletes who were diagnosed as havingsecond-degree hamstring strains. Subjects were divided into 2groups and both groups performed the same stretches, althoughwith a different frequency each day. Researchers found that thegroup who stretched more frequently regained normal kneeextension range of motion (ROM) in an average of 5.6 dayscompared to 7.3 days for the control group (p < .001). The inter-vention group also returned to normal, unrestricted activities in anaverage of 13.3 days compared to 15.0 days for the control group(p < .001).

Most of the existing research on hamstring flexibility hasfocused on different modes of stretching, such as ProprioceptiveNeuromuscular Facilitation (PNF) (Puentedura et al., 2011;Wallmann, Gillis, & Martinez, 2008); static stretching (Puenteduraet al., 2011; Wallmann et al., 2008; Wallmann, Mercer, &McWhorter, 2005); plyometric stretching and ballistic stretching(Samuel, Holcomb, Guadagnoli, Rubley, & Wallmann, 2008). Theyhave also compared different stretching intensities (Marshall et al.,2011) and frequencies (Feland & Marin, 2004). We could only findone older study (Kornberg & Lew, 1989) which examined the effectof neurodynamic ‘stretching’ on Australian Rules football playerswith grade one hamstring injuries. That particular study involved28 subjects with grade one hamstring injuries, who also demon-strated positive responses to the slump test (neurodynamic test).The researchers randomized 16 subjects to receive traditionalphysical therapy management, and 12 to receive traditionalmanagement plus slump stretching. The results indicated thatadding the slump stretch technique to traditional care was moreeffective (p < .001) in returning players to full function than thetraditional management alone (Kornberg & Lew, 1989). In thatparticular study, researchers used a neurodynamic ‘stretch’ or whatis now referred to as a ‘tensioner’ (Butler, 2000; Mintken et al.,2011) instead of the ‘slider’. We believe that this present study isthe only one in the current literature to apply a neurodynamicslider technique to healthy subjects with shortened hamstrings.Wechose to use a neurodynamic slider technique rather thana ‘tensioner’ because we wanted to assess for the effect of move-ment rather than stretch (which is a part of the ‘tensioner’) inaltering perceptions of stretch or pain associated with the SLR.

Please cite this article in press as: Castellote-Caballero, Y., et al., Effects ofmale soccer players. A pilot study, Physical Therapy in Sport (2012), http:

Mendez-Sanchez et al. (2010) completed a randomizedcontrolled pilot study on 8 healthymale soccer players to assess theimmediate effects of a sciatic nerve slider technique added tosustained hamstring stretching on lumbar and lower quadrantflexibility. Lower quadrant flexibility was assessed by the passivestraight leg raise test performed in exactly the same manner as forour study. One group of 4 players were assigned to receive bilateralhamstring stretching while supine for 5 min while the other groupof 4 received the same stretching plus a sciatic slider neuralmobilization technique on both sides. The slider technique in theirstudy consisted of placing each soccer player in supine with theneck supported in a flexed forward position and then applying hipand knee flexion concurrently, then alternating this with hip andknee extension and repeated the motions for 60 s. Both groupsdemonstrated improved flexibility over time; however, straight legraise of the left leg showed a significantly greater improvement inthe experimental group (Mendez-Sanchez et al., 2010). Theexperimental group also had greater improvements in lumbar andlower quadrant flexibility asmeasured by themodified Schöber testand slump test. The authors postulated that the observed changesmay have been secondary to decreasing neuromeningeal sensi-tivity; however, an alternative explanation may be that the neu-rodynamic sliders led to a modification of sensation such that thesoccer players’ perceptions of stretch or painwere altered (Weppler& Magnusson, 2010).

Such a proposal is further supported by a recent study con-ducted by Aparicio, Quirante, Blanco, and Sendin (2009). Theauthors examined the immediate effect of a suboccipital muscleinhibition (SMI) technique on hamstring flexibility (measured bythe forward flexion distance test; straight leg raise test; andpopliteal angle test) and pressure pain threshold (PPT) over myo-fascial trigger points (MTrPs) in the hamstring musculature.Seventy subjects comprised of 49 students from the PhysiotherapySchool of the University of Extremadura (Spain) and 21 soccerplayers from the Extremadura Football Club, were randomlyassigned to receive SMI or a placebo intervention. Results demon-strated that the SMI technique modified the flexibility of thehamstring muscles on all outcome measures, and furthermore,there was a significant difference in pressure algometry (PPT) forMTrPs in the right semimembranosus following the SMI (p ¼ .021)but not the left semimembranosus (p ¼ .079). The fact that sucha distant technique (suboccipital region) can have an immediateeffect on the flexibility and pressure pain thresholds in the

a neurodynamic sliding technique on hamstring flexibility in healthy//dx.doi.org/10.1016/j.ptsp.2012.07.004

Y. Castellote-Caballero et al. / Physical Therapy in Sport xxx (2012) 1e76

hamstrings may lend support to the ‘sensory theory’ proposed byWeppler and Magnusson (2010). It appears reasonable to suggestthat the observed increases in hamstring tissue extensibilityfollowing the SMI would have more likely come from changes inthe subjects’ perceptions of stretch or pain associated with theflexibility and pressure pain testing.

Although our study does not provide information about themechanism of action or change, it does suggest that neurodynamictreatment can significantly increase hamstring flexibility in a youngmale athletic population.

4.1. Limitations

The present research was designed as a pilot study, and itsfindings should be considered as tentative. Some limitations shouldbe acknowledged. The sample size was small and included onlyyoung males; thus, results cannot be generalized to other pop-ulations. Additionally, we only looked at differences in measure-ments after a week of intervention and it is not possible todetermine how long the observed increase in hamstring flexibilitymight have lasted. Furthermore, we did not conduct any long termfollow-up to determine if the observed changes in flexibilityresulted in any change in incidence of hamstring injuries within thegroups. Future research should involve larger sample sizes, perhapsinclude female soccer players to assess for gender differences, andexamine for more long term effects of neurodynamic interventions.Finally, despite the significant increase in flexibility for the neuro-dynamic intervention group, none of those players surpassed the75� mark (upper bound 95% CI ¼ 70.7�) indicating that theycontinued to have short hamstring syndrome (Ferrer, 1998; Hartig& Henderson, 1999). It is not known whether additional stretch-ing may have enabled these players to improve further and thiswould need further research.

5. Conclusion

The findings of this study suggest that a neurodynamic slidingtechnique can increase hamstring flexibility in male soccer players.Future research should compare neurodynamic techniques withother interventions. Such studies should address additional musclegroups and examine the duration of lengthening in repeatedmeasure designs.

Conflict of interest

None declared.

Ethical approval

This clinical trial received ethical from the Universidad deGranada, Spain and was also approved by Hospital Virgen de lasNieves, Servicio Andaluz de Salud, Spain.

Funding

None declared.

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