Tissue Flossing

Original Editor - Abbey Wright Top Contributors - Sophia Elina Potthoff, Abbey Wright, Claire Knott, Kim Jackson, Rucha Gadgil, Admin, Vidya Acharya, Candace Goh, Alexandra Stead and Tony Lowe  

Introduction

Tissue flossing is a myofascial intervention that involves applying an elastic latex band around a specific body region. It is used with a predetermined level of tension, followed by movement of the affected area. The technique is used with the aim of reducing pain, improving myofascial mobility, increasing joint Range of Motion (ROM), and optimising physical performance. It was established by Dr. Kelly Starrett and Glen Cordoza in 2013 and gained increasing popularity since then.

Although both Tissue Flossing and Blood Flow Restriction Training (BFRT) can influence blood flow through external compression, the two techniques differ considerably in their application and dosage. While BFRT typically uses a pneumatic cuff that allows the applied pressure to be controlled, Tissue Flossing uses elastic bands, making the pressure applied to the underlying tissue considerably more difficult to quantify and standardise. Therefore, Tissue Flossing should not be equated with conventional BFRT, despite potential similarities in their physiological mechanisms.

Mechanism of Action

Several mechanisms have been proposed to explain the potential effects of tissue flossing. Gao et al. describe a theoretical framework involving five potential mechanisms: pain modulation, fascial gliding, the sponge effect, soft tissue ischemia, and joint-related effects. However, these mechanisms remain largely theoretical, and the physiological basis underlying the clinical effects of tissue flossing has not yet been conclusively established.

Proposed Mechanisms

Calf flossing

The application of an elastic band under tension produces external compression of the underlying tissues and may alter local blood flow and fluid dynamics. The pain-modulating effects may be related to changes in sensory input associated with compression and movement, potentially influencing pain perception. The fascial glide hypothesis suggests that tissue flossing may temporarily alter the mobility between fascial and other soft tissue layers. The sponge effect proposes that compression followed by release may facilitate changes in local fluid movement. The soft tissue ischemia hypothesis builds on this circulatory mechanism, suggesting that the temporary restriction of blood flow during application, followed by reperfusion after removal of the band, leads to transient changes in tissue oxygenation that may contribute to subsequent physiological responses. Finally, the joint effect hypothesis proposes that compression and movement around a joint may influence joint-related sensory and mechanical responses.

Limitations of Current Evidence

These proposed mechanisms should be interpreted with caution, as direct evidence supporting each individual mechanism is currently limited. Further experimental research is required to determine which physiological processes contribute to the clinical effects observed following tissue flossing.

Potential Effects

The mechanisms may help explain some of the short-term physiological and clinical responses observed following tissue flossing. However, evidence for these proposed benefits remains variable, with studies reporting different outcomes depending on the population, body region, application protocol, and outcome measure. The potential clinical effects of tissue flossing are therefore listed below:

• reduced pain
• increased joint range of motion
• changes in muscle performance
• reduced exercise-induced muscle soreness
• improved recovery

Indication

Based on the currently available literature the evidence regarding specific indications remains limited and heterogeneous. The following potential indications are based on the clinical practice recommendations proposed by Cheatham and Baker:

Ankle flossing

• Impaired joint ROM
• Muscle strength and power
• Athletic performance
• Balance
• Tissue stiffness
• Achilles tendinopathy
• Osgood-Schlatter disease
• Shoulder pain
• Elbow pain
• Delayed onset of muscle soreness (DOMS)

Contraindications

Because tissue flossing involves applying external compression to the body, particular caution is required when applying the band over areas containing blood vessels. The applied pressure may affect local blood flow by compressing vascular structures, with the potential to reduce arterial inflow or restrict venous outflow. Therefore, the patient's vascular status and individual risk factors should be considered before application, and the band should be removed immediately if signs of impaired circulation, such as marked skin discolouration, numbness, tingling, or unusual pain, occur.

As no evidence-based consensus on contraindications for Tissue Flossing currently exists, the following conditions have been proposed as potential contraindications based on available literature, clinical considerations, and recommendations from related myofascial interventions. The following list provides examples of contraindications for flossing:

• Latex allergy
• Fragile or sensitive skin
• Open wounds, blisters, skin rash
• Cancer
• Medications that alter blood flow or sensations
• Unhealed or unstable bone fracture
• Connective tissue disorder e.g. Ehlers-Danlos syndrome, Marfan syndrome
• Advanced Osteoporosis

Application

The tissue flossing band is typically applied circumferentially around the target body region, such as a joint or area of soft tissue, using approximately 50% overlap between successive layers. The band is generally applied in a distal-to-proximal direction with a stretch of approximately 50–90% of its maximum length. Once applied, the band is typically left in place for up to 10 minutes while the treated area is exposed to active and passive movements.

The following videos provide practical examples of tissue flossing application for smaller and larger body regions and demonstrate the application technique and associated movements.

Quadriceps:

Ankle:

Clinical Implications

Current evidence suggests that tissue flossing may provide short-term effects on outcomes such as pain, joint range of motion, and physical performance. However, the clinical significance of these findings remains uncertain due to limitations in the available research.

The current evidence base is characterised by considerable heterogeneity in study populations, body regions, application techniques, band tension, treatment duration, and outcome measures. In addition, many studies have small sample sizes and methodological limitations, making it difficult to compare findings across studies or establish consistent clinical recommendations.

Therefore, tissue flossing may be considered as a potential adjunct to conventional physiotherapy interventions rather than a standalone treatment. Clinicians should consider the available evidence, individual patient characteristics, and appropriate precautions when deciding whether to use tissue flossing. Further high-quality, adequately powered studies using standardised application protocols and clinically relevant outcome measures are needed to determine its effectiveness and establish evidence-based recommendations for clinical practice.

The following video provides an overview of recent studies on tissue flossing and discusses the quality and limitations of the available evidence.

Summary

Tissue flossing is a myofascial intervention that combines elastic band compression with movement. It may have short-term effects on pain, joint range of motion, and physical performance. However, the underlying mechanisms remain largely theoretical and the current evidence is heterogeneous, with differences in study populations, application protocols, and outcome measures. Tissue flossing may therefore be used as an adjunct to physiotherapy, while further high-quality research is needed to establish evidence-based recommendations.