Bringing Light Into the Dark: Effects of Compression Clothing on Performance and Recovery

Abstract

To assess original research addressing the effect of the application of compression clothing on sport performance and recovery after exercise, a computer-based literature research was performed in July 2011 using the electronic databases PubMed, MEDLINE, SPORTDiscus, and Web of Science. Studies examining the effect of compression clothing on endurance, strength and power, motor control, and physiological, psychological, and biomechanical parameters during or after exercise were included, and means and measures of variability of the outcome measures were recorded to estimate the effect size (Hedges g) and associated 95% confidence intervals for comparisons of experimental (compression) and control trials (noncompression). The characteristics of the compression clothing, participants, and study design were also extracted. The original research from peer-reviewed journals was examined using the Physiotherapy Evidence Database (PEDro) Scale. Results indicated small effect sizes for the application of compression clothing during exercise for short-duration sprints (10-60 m), vertical-jump height, extending time to exhaustion (such as running at VO2max or during incremental tests), and time-trial performance (3-60 min). When compression clothing was applied for recovery purposes after exercise, small to moderate effect sizes were observed in recovery of maximal strength and power, especially vertical-jump exercise; reductions in muscle swelling and perceived muscle pain; blood lactate removal; and increases in body temperature. These results suggest that the application of compression clothing may assist athletic performance and recovery in given situations with consideration of the effects magnitude and practical relevance.

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BRIEF REVIEW
International Journal of Sports Physiology and Performance, 2013, 8, 4-18
© 2013 Human Kinetics, Inc.
Bringing Light Into the Dark: Effects of Compression
Clothing on Performance and Recovery
Dennis-Peter Born, Billy Sperlich, and Hans-Christer Holmberg
To assess original research addressing the effect of the application of compression clothing on sport perfor-
mance and recovery after exercise, a computer-based literature research was performed in July 2011 using the
electronic databases PubMed, MEDLINE, SPORTDiscus, and Web of Science. Studies examining the effect
of compression clothing on endurance, strength and power, motor control, and physiological, psychological,
and biomechanical parameters during or after exercise were included, and means and measures of variability
of the outcome measures were recorded to estimate the effect size (Hedges g) and associated 95% condence
intervals for comparisons of experimental (compression) and control trials (noncompression). The character-
istics of the compression clothing, participants, and study design were also extracted. The original research
from peer-reviewed journals was examined using the Physiotherapy Evidence Database (PEDro) Scale.
Results indicated small effect sizes for the application of compression clothing during exercise for short-
duration sprints (10–60 m), vertical-jump height, extending time to exhaustion (such as running at VO2max or
during incremental tests), and time-trial performance (3–60 min). When compression clothing was applied
for recovery purposes after exercise, small to moderate effect sizes were observed in recovery of maximal
strength and power, especially vertical-jump exercise; reductions in muscle swelling and perceived muscle
pain; blood lactate removal; and increases in body temperature. These results suggest that the application of
compression clothing may assist athletic performance and recovery in given situations with consideration of
the effects magnitude and practical relevance.
Keywords: blood ow, cardiac output, heart rate, muscle damage, oxygen uptake, oscillation, venous hemo-
dynamics
Born and Sperlich are with the Dept of Sport Science, University
of Wuppertal, Wuppertal, Germany. Holmberg is with the Swed-
ish Winter Sports Research Center, Mid Sweden University,
Östersund, Sweden.
In the past 2 decades, various forms of compression
clothing have been used by elite and recreational athletes.
In running1,2 and cycling,3,4 lower body compression
clothing such as knee-high socks, shorts, and full-length
tights are the most common types of compression gar-
ments. To improve hemodynamics, “graduated compres-
sion” with pressure decreasing from distal to proximal
is recommended.5 Upper- or full-body compression is
applied in various sports to improve maximal strength
and power, such as bench-press exercises6 and throwing
performance in cricket players.7
The increasing popularity of compression clothing in
different sports is likely due to accumulating evidence of
enhanced performance1,8 and recovery.9–11 Performance
in maximal strength and power tasks, such as vertical
jumping, has been shown to improve with the application
of compression clothing; this is possibly due to increased
proprioception and reduced muscle oscillation.8 However,
endurance exercise such as submaximal running seems
to be unaffected,2,12 even if compression clothing has
been shown to improve venous hemodynamics13 and
increase deeper-tissue oxygenation14 and the clearance
of metabolites.15 From a thermoregulatory point of view,
compression clothing has been shown to increase muscle
temperature,16 potentially by reducing skin blood ow.17
Currently, there has been 1 review summarizing
the ndings of the application of compression cloth-
ing for exercise and recovery, and its conclusions were
based mostly on the statistically signicant results in the
reviewed articles.18 That review also concludes that there
are some isolated indications for physical and physiologi-
cal effects, including attenuation of muscle oscillation,
improved joint awareness, perfusion augmentation, and
altered oxygen use at submaximal intensities, whereas the
effects of compression clothing on indicators of recovery
performance remain inconclusive.
The practical application of statistical signicance
when comparing the ndings of compression and non-
compression conditions is open to discussion since it
may be inuenced by sample size and data variance.
By increasing the number of participants, and decreas-
ing variance, statistical signicance will be achieved
when comparing an experimental and a control trial.19
Therefore, it seems more relevant to calculate effect sizes

Compression Clothing 5
(ESs) to compare and quantify the various ndings and
detect the practical meaningfulness of the application
of compression clothing. When ndings are based on
individual studies and transferred to general statements,
the focus moves to their practical relevance instead of
relying solely on statistical signicance.19 The approach
using Hedges g was shown to optimize calculation of the
ES by using a pooled standard deviation of both groups,
hence standardizing mean differences.20 This quantita-
tive approach has been implemented in other systematic
reviews in exercise science.21–23
In general, the heterogeneity of test procedures,
with differing types and amounts of compression, makes
it difcult to perform a comparison between different
studies evaluating compression clothing in an athletic
population. Our intent was to review the literature to
identify possible benets of compression clothing for
performance and recovery.
The aims of this systematic review regarding the
application of compression clothing for performance and
recovery were to summarize results from existing data;
identify the benets for endurance and strength, as well as
power and motor control; quantify effects on physiological,
psychological, and biomechanical parameters; identify
possible underlying mechanisms for observed results;
and provide recommendations for athletes and consumers.
Methods
Data Sources
A computer-based literature research was performed
during July 2011 using the electronic databases PubMed,
MEDLINE, SPORTDiscus, and Web of Science. In addi-
tion, the reference lists from these articles and previously
known cases were cross-referenced for further relevant
studies. The following key words were used to retrieve
pertinent articles: athlete, balance, blood ow, blood lac-
tate, compression clothing, endurance, exercise, fatigue,
garments, heart rate, muscle damage, pain, swelling,
oscillation, oxygenation, oxygen uptake, performance,
perceived exertion, power, proprioception, recovery,
strength, stroke volume, textiles, thermoregulation, time
to exhaustion, and time trial.
Study Selection
Peer-reviewed studies were included if they investigated
any kind of compression clothing in relation to endurance
(n = 15), strength (n = 3), power (n = 8), or both endurance
and power (n = 5) during or after exercise. The studies had
to assess physiological, biomechanical, or psychological
parameters during and/or after exercise. Only studies that
presented absolute data as means and measures of vari-
ability for the calculation of ESs from an experimental
(compression) and a control group (noncompression) were
included. Finally, the research must have been conducted
on participants without any cardiovascular, metabolic, or
musculoskeletal disorders (Figure 1).
Quality Assessment
Each study meeting the inclusion criteria was addition-
ally evaluated with the Physiotherapy Evidence Database
(PEDro) Scale by 2 independent reviewers.24 On the
PEDro scale an item answered with “yes” adds 1 point
to the score and “no” contributes 0 points, with a maxi-
mum of 10 points. This method has been used in previ-
ous systematic reviews for the methodological quality
assessment of studies.25–27
Statistical Analysis
To compare and quantify the various ndings of perfor-
mance and recovery, ESs for each study were determined
as proposed by Glass.28 For each parameter, the ES
(Hedges g) and associated 95% condence interval were
calculated. Hedges g was computed using the difference
between means of an experimental (compression) and
control (noncompression) group divided by the average
population standard deviation.20 To optimize ES calcula-
tion and estimate the standard deviation for Hedges’ g,
baseline standard deviations of experimental and control
groups were pooled.20 According to standard practice, the
ESs were then dened as trivial (<.10), small (.10–.30),
moderate (.30–.50), or large (>.50).19 All statistical analy-
ses were carried out using MedCalc, version 11.5.1.0
(MedCalc, Mariakerke, Belgium).
Results
Of the initial 423 studies identied, 31 studies were exam-
ined using the PEDro score, with an average score of 6.1,
ranging from 5 to 9 (maximum possible score = 10 points).
The characteristics of the participants and the com-
pression clothing, measured parameters, and the protocols
for each study are summarized in Table 1. The calculated
ESs relating to the effects of applying compression cloth-
ing for exercise and performance and/or recovery are
presented in Figures 2 and 3.
The sample sizes (n = 5–21), age (19–39 y) and gender
of the participants (male n = 22, female n = 3, mixed gender
n = 5, no gender information n = 1), and type of compres-
sion clothing (shirts n = 2, tights n = 14, stockings n = 2,
shorts n = 3, knee-high socks n = 9, whole-body compres-
sion consisting of tights and a shirt n = 4) that were applied
in the reviewed studies showed a high variability (Figure
4). Only 11 studies included elite or well-trained subjects,
while 20 included recreational athletes or participants
competing at a regional level. Overall, 16 studies used a
graduated compression, with pressure decreasing from
distal to proximal. Moreover, 19 studies provided data
including the amount of exerted pressure ranging from 8 to
40 mmHg, whereas 12 studies reported no data (Table 1).
Exercise and Performance
Altogether, the ES results indicate that compression cloth-
ing had either small positive or no effects on performance
during exercise. While maximum oxygen uptake was

6 Born, Sperlich, and Holmberg
Figure 1 — Process of study selection for the inclusion in the systematic review.
not affected (ES = 0.08, Figure 2),1,4,15,29–32 performance
during maximal endurance exercise such as time to
exhaustion (Table 1)29,31–36 and time-trial performance
(3–60 min)12,15,37 indicated small positive effects (ES =
0.15). In addition, endurance-related parameters such as
submaximal oxygen uptake (ES = 0.01),2,29,32,36,38 blood
lactate concentration during continuous exercise (ES =
–0.04),2–4,7,29,31,32,36–40 blood gas such as saturation2,7,29
and partial pressure of oxygen (ES = 0.01),7,29 and cardiac
parameters including heart rate,2,32,37,38,40 cardiac output,
cardiac index, and stroke volume (ES = –0.08) 2 were not
affected by the application of compression compared with
noncompression clothing.
Small positive ESs (ES = 0.12, Figure 2) were
detected for improvements in single and repeated sprint-
ing (10–60 m),7,16,30,39,41 as well as vertical jumping (ES =
0.10),30,37,39,42 in participants wearing compression cloth-
ing. Peak leg power measured on a cart dynamometer16
and performance during maximal-distance throwing7
were not affected by compression clothing (ES = 0.00). In
addition, there were no effects on balance, joint-position
sense,30 or arm tremble during bench press6 (ES = –0.02).
No mean effects were observed for changes in the
perceived exertion during or immediately after exercise
(ES = 0.05, Figure 2)1,7,12,29,37,38,41 when compression
clothing was applied.

7
Table 1 Studies Investigating the Effect of Compression Clothing on Performance and Recovery Enhancement
Characteristics of Participants
Characteristics of
Compression Clothing
Study
Sample size,
gender, age
(y) Athletic category Type
Applied
pressure
(mmHg) Measure
Study protocol (occasion when
compression clothing was applied)
Effects of
compression clothing
Ali et al37 12, M+F, 33
± 10
Competitive runners (VO2max 68.7 ±
6.2 mL ∙ kg–1 ∙ min–1)
Socks (G) 15, 21, 32 P, R 10-km TT (during exercise) TT↔, La↓, CP↑↓,
jump↑↓, RPE↑↓,
Dascombe
et al32
11, M, 28
± 10
Well-trained runners and triathletes
(VO2max 59.0 ± 6.7 mL ∙ kg–1 ∙ min–1)
Tights (G) 16–22, 14–19 P Incremental running test and TTE at 90%
VO2max. Tempamb: 22°C ± 2°C (during
exercise)
VO2max↑, TTE↔,
VO2↑↓, La↓, CP↔
Sperlich et
al2
15, M, 22 ± 1 Well-trained runners and triathletes
(VO2max 57.2 ± 4.0 mL ∙ kg–1 ∙ min–1)
Socks (G) 10, 20, 30, 40 P 45-min treadmill running at 70% of VO2max
(during exercise) VO2↑↓, La↑↓, CP↑↓,
SO2↑↓, HR↑
Ali et al38 10, M, 36
± 10
High-performance runners and tri-
athletes (VO2max 70.4 ± 6.1 mL ∙ kg–1
∙ min–1)
Socks (G) 12–15, 23–32 P, R 40-min treadmill running at 80% VO2max
(during exercise) VO2↑↓, La↑↓, CP↑↓,
RPE↑↓, jump↑↓
Cabri et al40 6, M, 31 ± 7 Trained runner (5000-m best time
1445 ± 233 s)
Socks P, R Submaximal run (5000 m) at a velocity of
85% of the 5000-m best time (during exer-
cise, 2 min after)
La↔, CP↑
Dufeld et
al39
11, M, 21 ± 3 Regional rugby players (3–4 training
sessions/wk and 1 game/wk)
Tights 10–30 P, R Intermittent sprinting: 10 min (1 × 20-m
sprint and 10 squat jumps/min; during
exercise, 24 h after)
La↑↓, jump↑↓,
sprint↑↓, DOMS↑,
CK↑↓, damage
marker↑↓, HR↔, pH↑
Goh et al33 10, M, 29
± 10
Recreational runners (VO2max 58.7 ±
2.7 mL ∙ kg–1 ∙ min–1)
Tights (G) 9–14 P 20 min at 1st ventilatory threshold fol-
lowed by run to exhaustion at VO2max at
10°C and 32°C (during exercise)
TTE↑
Jakeman et
al11
8, F, 21 ± 2 Physically active (>3 times/wk) Tights (G) 15–17 R Intermittent jumping: 10 × 10 drop-jumps
(1 jump/10 s) with 1-min rest between sets
(compression 12 h after exercise)
CK↑↓
Jakeman et
al48
8, F, 21 ± 2 Physically active (>3 times/wk) Tights (G) 15–17 R Intermittent jumping: 10 × 10 drop-jumps
(1 jump/10 s) with 1-min rest between sets
(compression 12 h after exercise)
CK↑↓
Kraemer et
al10
20, M+F, 23
± 3
Resistance-trained (>2 y) WBC R Barbell resistance-training workout: 8
exercises, 3 × 8–10-RM with 2- to 2.5-min
rest between sets (compression 24 h after
exercise)
DOMS↑
Rimaud et
al3
8, M, 27 ± 1 Trained athletes (VO2max 53.3 ± 2.7
mL ∙ kg–1 ∙ min–1)
Socks (G) 12–22 P Incremental cycling test (during exercise) La↓
Sear et al36 8, M, 21 ± 1 Team amateur athletes (VO2max 57.5
± 3.7 mL ∙ kg–1 ∙ min–1)
WBC P 45-min high-intensity interval treadmill
running (during exercise) TTE↑, VO2↑↓, La↑
(continued)

8
Characteristics of Participants
Characteristics of
Compression Clothing
Study
Sample size,
gender, age
(y) Athletic category Type
Applied
pressure
(mmHg) Measure
Study protocol (occasion when
compression clothing was applied)
Effects of
compression clothing
Sperlich et
al29
15, M, 27 ± 5 Well-trained runners and triathletes
(VO2max 63.7 ± 4.9 mL ∙ kg–1 ∙ min–1)
Socks,
tights,
WBC
20 P 15-min treadmill running at 70% VO2max
followed by running to exhaustion at vmax
of previous incremental test (during exer-
cise)
VO2max↑, TTE↓,
VO2↑↓, La↑↓, pO2↑↓,
SO2↑↓, RPE↑
Davies et
al43
11, M+F, 20
± 1
Netball and basketball, university
level
Tights (G) 15 R Intermittent jumping: 5 × 20 drop-jumps
with 2-min rest between sets (compression
48 h after exercise)
Jump↑, sprint↑↓,
swelling↔, DOMS↑↓,
CK↓, damage
marker↑↓
Higgins et
al34
9, F, 23 ± 5 Elite netball players Tights P Intermittent sprinting and jumping in
a simulated netball game (4 × 15 min;
during exercise)
TTE↑
Houghton et
al41
12, M, 21 ± 2 Field hockey, amateur (VO2max 58.6
± 5.5 mL ∙ kg–1 ∙ min–1)
Shorts
and shirt
P, R Intermittent sprinting: 20-m sprints in
a simulated hockey game (4 × 15 min;
during exercise)
Sprint↓, RPE↑↓, HR↓,
Kemmler et
al31
21, M, 39
± 11
Moderately trained runners (VO2max
52.0 ± 6.1 mL ∙ kg–1 ∙ min–1)
Socks (G) 24 P Incremental treadmill running test (during
exercise) TTE↑, VO2max↑, La↔
Silver et al65, M, 24 ± 6 Highly strength-trained 1-RM bench
press (>125% BW)
Shirt P 1-RM bench press, quantication of verti-
cal and horizontal bar movements (during
exercise)
Motor control↑↓
Dufeld et
al16
14, M, 19 ± 1 Regional rugby players Tights P, R Intermittent sprinting: 10- and 20-m
sprints in a simulated rugby game (4 × 15
min), tempamb 16–18°C (compression 18 h
after exercise)
Sprint↑, strength &
power↑↓, CK↑↓,
temp↑
French et
al47
10, M, 24 ± 3 Recreational/regional soccer and
rugby players
Tights (G) 10–12 R 6 × 10 parallel squats at 100% BW + 11th
repetition at 1-RM (compression 12 h after
exercise)
CK↑↓, damage
marker↑↓
Montgom-
ery et al44
10, M, 19 ± 2 Regional basketball players training
8–10 h/wk
Tights 18 R 3-day tournament with one 48-min game
each day (compression 18 h after exercise) Jump↑, sprint↓
Montgom-
ery et al45
10, M, 19 ± 2 Regional basketball players training
8–10 h/wk
Tights 18 R 3-day tournament with one 48-min game
each day (compression 18 h after exercise) Swelling↑, DOMS↑
Scanlan et
al4
12, M, 21 ± 4 Amateur cyclists (VO2max 55.2 ± 6.8
mL ∙ kg–1 ∙ min–1)
Tights (G) 9–20 P 1-h time trial (on cycling ergometer;
during exercise) VO2max ↓, La↑↓
Table 1 (continued)

9
Ali et al12 14, M, 22 ± 1 Amateur runners: (1) VO2max 56.1
± 0.4 mL ∙ kg–1 ∙ min–1, (2) VO2max
55.0 ± 0.9 mL ∙ kg–1 ∙ min–1
Socks (G) 18–22 P, R 2 × 20-m shuttle-runs (separated by 1 h)
and 10-km TT (road run; during exercise)
TT↓, RPE↔,
DOMS↔, HR↔,
Dufeld et
al7
10, M, 22 ± 1 Regional cricket players WBC P, R Maximal-distance throwing, throwing
accuracy, and intermittent sprinting: 20-m
sprints/min for 30 min. Tempamb 15°C ±
3°C (during exercise, 24 h after)
La↑, SO2↓, pO2↓,
sprint↑↓, strength &
power↑, RPE↓, HR↑,
pH↓, CK↑, temp↑
Bringard
et al1
6, M, 31 ± 5 Well-trained runners (VO2max 60.9 ±
4.4 mL ∙ kg–1 ∙ min–1)
Tights P, R Energy cost at 10, 12, 14, 16 km/h (tem-
pamb 31°C) and 15-min treadmill running
at 80% VO2max. Tempamb 23.6°C (during
exercise)
VO2max↓, RPE↑,
temp↑
Maton et
al35
15, M, 32 ± 6 Healthy (type of sport not specied) Stockings
(G)
15–21 P, R Maintaining 50% of 1-RM ankle dorsiex-
ion to exhaustion (during exercise, 10 min
after)
TTE↓, strength &
power↑
Trendell et
al46
11, M, 21 ± 3 Recreational athletes (type of sport
not specied)
Stockings
(G)
R 30-min downhill treadmill walking (6
km/h, 25% grade; compression 48 h after
exercise)
DOMS↑, damage
marker↑↓
Bernhardt et
al30
13, M+F, 26 ± Healthy active students (type of
sport not specied)
Shorts P, R Active range of motion, agility test, bal-
ance test, joint-angle replication; 20-m
sprint, vertical jump; 20-m shuttle run
(during exercise)
VO2max↔, jump↔,
sprint↑, motor con-
trol↓
Kraemer et
al42
18, M+F, 21
± 3
University volleyball players Shorts P 10 consecutive countermovement jumps
(during exercise) Jump↑↓
Berry et al15 6, M, 23 ± 5 Well-trained: (1) VO2max 52.8 ± 8.0
mL ∙ kg–1 ∙ min–1, (2) VO2max 59.9 ±
6.8 mL ∙ kg–1 ∙ min–1
Socks (G) 8–18 P Incremental treadmill running test to deter-
mine VO2max and 3 min at 110% VO2max
(on cycling ergometer; during exercise)
VO2max↑, TT↔
Abbreviations: M, male; F, female; VO2, oxygen uptake; G, graduated; P, performance; R, recovery; TT, time trial; ↔, no effect from compression; La, blood lactate concentration; ↓, negative effect from compres-
sion; CP, cardiac parameters (HR, cardiac output, cardiac index, stroke volume); ↑↓, contradictory results: positive, as well as negative, effects from compression; RPE, rating of perceived exertion; tempamb, ambient
temperature; ↑, a positive effect from compression; TTE, time to exhaustion; SO2, oxygen saturation; HR, heart rate; jump, vertical-jump exercise; Sprint, short-duration sprinting; DOMS, delayed onset of muscle
soreness; CK, creatine kinase; damage marker, additional muscle damage marker; WBC, whole-body compression; 1-RM, 1-repetition maximum; pO2, oxygen partial pressure; Swelling, muscle swelling; strength &
power, strength and power exercise; temp, body temperature; BW, body weight.

10
Figure 2 — Effect sizes of the application of compression clothing on performance enhancement.

11
Figure 3 — Effect sizes of the application of compression clothing on recovery enhancement.

12 Born, Sperlich, and Holmberg
Figure 4 — Different types of compression applied in the
31 studies: a) shirt (n = 2), tights (n = 14), and whole-body
compression (n = 4); b) shorts (n = 3) and knee-high socks (n
= 9); and c) stockings (n = 2).
Recovery
The current analysis revealed small positive effects on
recovery of strength and power tasks (ES = 0.10) such
as peak leg power on a cart dynamometer,16 maximal-
distance throwing,7 and isolated plantar exion.35 When
applying compression compared with noncompression
clothing, recovery of vertical-jump performance was
also positively affected (ES = 0.13, Figure 3).37–39,43,44
However, the recovery of short-sprint ability (10–60 m)
was negatively affected by the use of compression cloth-
ing (ES = –0.13).7,16,30,39,43,44
The application of compression clothing had no
effect on heart-rate recovery (ES = 0.07, Figure 3).7,12,39,41
On the other hand, our analysis discovered small effects
on postexercise lactate removal (ES = 0.20),7,39,40
although there was no effect on plasma pH (ES = 0.02).7,39
Recovery-related parameters showed a moderate
effect on the reduction of muscle swelling (ES = 0.35,
Figure 3)43–45 and delayed onset of muscle soreness (ES
= 0.47)12,16,39,43–46 when compression clothing was worn
for 12 to 48 hours after exercise. Small negative effects
regarding muscle-damage markers were detected for
levels of creatine kinase (ES = –0.10),7,11,16,39,43,47,48 and
no effects for other myocellular proteins were found (ES
= –0.01).39,43,46,47
Body temperature was highly affected by the use of
compression clothing, with large increases (ES = 1.38,
Figure 3) during and after intermittent high-intensity exer-
cise (15–18°C)7,16 and submaximal running (23–31°C).1
Discussion
The ES calculations indicated small ESs for the appli-
cation of compression clothing during exercise for
improving short-duration sprints (10–60 m), vertical-
jump height, and time to exhaustion (such as running at
VO2max or during incremental tests), as well as time-trial
performance (3–60 min). When compression clothing
was applied for recovery purposes 12 to 48 hours after
exercise, small or moderate effects were also observed
for recovery of maximal strength and power performance,
recovery of vertical-jump performance, blood lactate
removal, reductions in muscle swelling and perceived
muscle pain, and increased body temperature.
It is worth mentioning that compression clothing is
also used by individuals who run but suffer from medial
tibial stress syndrome, for example (a common running
injury), or by individuals who suffer from chronic venous
insufciency. Therefore, the current results based on
healthy individuals may not be the same in injured and
unhealthy individuals who practice sports.
Endurance Exercise
While previous research concluded that there is some
evidence that submaximal oxygen use is altered by the
application of compression clothing,18 our ES calcula-
tion cannot conrm those ndings in general. Based on
the average ES calculations, none of the physiological
markers during exercise, such as oxygen uptake, blood
lactate concentration during continuous exercise, blood
gases, or cardiac parameters, were affected (Figure 2).
However, 7 studies that evaluated time to exhaustion
and 3 examining time-trial performance demonstrated
positive effects attributed to the application of compres-
sion clothing. It has been shown that time-to-exhaustion
tests are less reliable (coefcient of variation >10%) than
constant-duration tests such as time trials (coefcient of
variation <5%),49 which may explain why these ndings
are not in line with the possible underlying physiological
markers. Since it is difcult to create a placebo condi-
tion for compression clothing, it cannot be excluded
that extended time to exhaustion is due to improved
perceptions and a result of the participants’ intuitions of
expected ndings.12 But the overall sensation of vitality
plays a crucial role in exercise performance,50 and any
changes in perceived exertion during exercise may serve
as an ergogenic aid for improving performance regardless
of potential physiological effects.7
Earlier research has recommended applying gradu-
ated compression clothing, with pressure decreasing
continuously from distal to proximal to improve hemody-

Compression Clothing 13
namics.5 Due to the various differences in leg dimensions
among a given population, it was recommended that com-
pression clothing be custom made and individually tted
to have a proper amount of pressure on the various parts
of the limbs.43 None of the reviewed studies indicated
the use of custom-made compression clothing, and 17
of 31 studies applied graduated compression. Therefore,
the lack of effects on physiological parameters such as
oxygen uptake or cardiac parameters might partly be due
to insufcient or inappropriate compression properties of
the applied compression clothing.
Strength and Power Exercise
While MacRae et al18 reported mixed results for jumping
performance and that sprinting was unaffected by the
application of compression clothing, our ES calculation
revealed small positive effects on single and repeated
sprint performance and vertical jumping. Repeated-
sprint ability, and short-duration sprints separated by
short recovery periods, was shown to rely on metabolic
and neuronal factors such as H+ buffering, oxidative
capacity, muscle activation, and muscle-ber-recruitment
strategies.51 Since our ES calculation indicated positive
effects on lactate removal after and between bouts of
high-intensity exercise, the application of compression
clothing seems to aid performance and recovery. It is
suggested that hemodynamic and neuronal mechanisms
such as improved venous return,5,13,52 enhanced arterial
inow,53 altered muscle-ber-recruitment patterns,1,50 and
altered proprioception54,55 account for these performance
improvements (Figure 5).
Venous Return. The blood is driven through the
vascular system by the propulsive force of each heartbeat,
with the blood pressure being almost zero when the blood
enters the venous system. In addition, gravity creates
a hydrostatic force of 80 to 100 mmHg in an upright
body position that counteracts venous return.56 Since
unidirectional valves are located in the veins, the blood is
directed toward the heart with each muscle contraction of
the peripheral limbs due to compression on the veins. In
shifting supercially located blood to the deeper venous
system,5 the application of compression clothing supports
the valve system and aids venous hemodynamics.5,13,52
Improved venous hemodynamics have been sug-
gested to result in increased end-diastolic lling of the
heart, increasing stroke volume and cardiac output.12
Since stroke volume is a limiting factor for performance,57
the application of compression clothing could serve as
an ergogenic aid. In this context, Sperlich et al2 applied
0, 10, 20, 30, and 40 mmHg of sock compression to the
calf muscles of runners and reported no changes in car-
diac output, cardiac index, or stroke volume. From these
knee-high-sock compression data, it remains questionable
whether the improved venous hemodynamics (stimulated
by a fairly low area of compressed calf muscles) will
affect central circulatory and cardiac parameters such as
stroke volume and heart rate. However, the application of
compression clothing may enhance removal of metabo-
lites and supply of nutrients,58 which is in line with the
ndings of the ES calculation showing improved lactate
removal (Figure 3).
Arterial Inflow. Similar to the improvements in venous
hemodynamics, the application of compression clothing
was shown to improve arterial inflow to forearm
muscles.53 This improvement was associated with
enhanced local blood ow and improved oxygen delivery
and muscle oxygenation.14 In general, the diameter
of the arteries and arterioles is inuenced by changes
in the transmural pressure gradient.59 The so-called
myogenic response provides a constant blood ow in the
precapillary vessels with each heartbeat pumping blood
into the circulation. As the pressure of the compression
clothing is transmitted into the deeper underlying tissue,60
the vessels’ transmural pressure gradient decreases.61 The
myogenic response of the arteries and arterioles leads to
vasodilatation and favors arterial inow to the muscle,
hence increasing local blood inow.53
In supporting venous5,13,52 and arterial blood ow,53
the wearing of compression clothing was associated
with increased clearance of metabolites and supply
of nutrients.58 Since repeated-sprint ability relies on
metabolic factors such as H+ buffering and oxidative
capacity, the application of compression clothing could
serve as an ergogenic aid.51 The ES calculation supports
this in showing positive effects of the use of compres-
sion clothing on lactate removal during high-intensity
exercise. Therefore, compression clothing may improve
performance, especially during high-intensity exercise,
by supporting hemodynamics.
Neural Mechanisms. Power production, especially
short-duration sprints, relies on neural factors such
as muscle activation and recruitment strategies.51
Compression clothing has been linked to improved
proprioception, which is the awareness of the body
segments and position in space, allowing the individual to
know the direction, acceleration, and speed of the limbs
during movement.62 Sensory feedback is provided by
mechanoreceptors located in the skin, muscles, ligaments,
joint capsules, and connective tissue.62 It has been shown
that the activation of these receptors reduces presynaptic
inhibition,63,64 thus increasing sensory feedback.30 The
use of compression clothing most likely activates the
mechanoreceptors in the supercial tissues, enhances
sensory feedback,65 and improves proprioception.54,55
Since neural factors such as muscle activation and
muscle-fiber-recruitment strategies influence power
production,51 improved proprioception from the
application of compression clothing corresponds with the
ES calculation showing positive effects on short-sprint
ability and vertical-jump exercise.
Mechanical Properties. It has been shown that
compression clothing decreases oscillatory displacement
of the leg muscles during vertical jumping8,50 and reduces
the number of recruited muscle bers as detected by a
decrease in myoelectric activity.66 Therefore, decreased
energy expenditure during submaximal running,1 delayed

14
Figure 5 — Biological and psychological mechanisms underlying the application of compression clothing.

Compression Clothing 15
fatigue during repetitive vertical-jump exercise,50 and
reduced structural damage during intermittent sprinting39
were related to decreased oscillatory displacement of the
leg muscles by the application of compression clothing.
In this case, a fairly high amount of pressure seems to
be necessary to reduce the oscillatory displacement.
Since only 20 of 31 of the reviewed studies indicated the
amount of applied pressure, it is difcult to conclude the
optimal amount of pressure for certain exercise modes.
Future research is needed to clarify the optimal amount
of pressure exerted by compression clothing to reduce
oscillatory displacement without negatively affecting
hemodynamics.
Recovery 24 to 48 Hours After Exercise
The ES calculation confirms the findings of earlier
research18 concluding an improved recovery of various
power and torque measurements with the application
of compression clothing 24 to 48 hours after fatiguing
exercise. Although jumping exercise was not affected
in a previous analysis,18 our ES calculation showed an
improved recovery of vertical jumping (ES = 0.10).
These ndings may be explained by other physiological
markers such as reductions in muscle swelling (ES =
0.35), delayed onset of muscle soreness (ES = 0.47), and
increased body temperature (ES = 1.38). Most studies
that investigated the effect of compression on recovery
applied compression clothing during and/or after exer-
cise. Applying compression exclusively during continu-
ous exercise did not show any benets for recovery 24
hours after exercise.38 Therefore, it seems essential to
wear compression clothing for at least 12 to 24 hours
after exercise to improve recovery.
MacRae et18 concluded that compression garments
produced mixed results for markers of muscle damage
and inammation, as well as immediate and delayed
onset of muscle soreness. The current ES calculation
revealed negative effects on levels of creatine kinase
(ES = –0.10) but no effect on other myobrillar proteins
through the application of compression clothing (ES =
–0.01). However, the reduction in muscle soreness 24 to
48 hours after exercise showed medium positive effects
(ES = 0.47) with the use of compression clothing. The
application of compression clothing was suggested
to improve recovery after muscle-damaging exercise
protocols by enhancing lymphatic outow, thus reduc-
ing postexercise muscle swelling and pain67 (Figure 5).
Furthermore, increased arterial inow14,53 and venous
return5,13,52 were associated with increased clearance of
cellular waste products, potentially enhancing cellular
repair processes.43,46
Lymphatic Outflow. Especially after high-intensity
exercise, muscle pain and swelling can occur due to
structural damage to the contractile elements of the
muscles.68,69 The following necrosis of the damaged
muscle cells and the infiltration of neutrophil cells
(immune cells) result in an inammatory response.68
Furthermore, the proteins of the damaged contractile
elements are released into the interstitial uid, contributing
to elevated tissue osmotic pressure.67 To equalize the
osmotic gradient, fluid from the circulatory system
is absorbed, which increases the interstitial uid and
intracompartmental pressure, resulting in edema.67
Applying compression clothing may reduce exercise-
induced edema by promoting lymphatic outow and
transporting the profuse uid from the interstitium of
the muscle back into the circulation.67,70 Thereby, intra-
compartmental pressure is reduced, decreasing pain67 and
serving as a nonpharmaceutical treatment of edema after
high-intensity exercise in trained athletes.10
It remains unclear why the removal of muscle-
damage markers such as creatine kinase was negatively
affected, whereas other muscle-damage markers such as
lactate dehydrogenase were unaffected. Nevertheless,
these enzymes serve as global markers for damage to
contractile elements and act as indicators of recovery
rather than providing evidence for its progress.71,72
Thermoregulation. The application of compression
clothing showed a large positive effect on body
temperature (ES = 1.38). In general, clothing by itself
imposes a physical barrier to heat transfer and hinders
sweat evaporation from the skin by representing a layer
of insulation.73
In this context, an interaction between muscle blood
ow and skin and muscle temperature has been reported,74
and compression clothing has been shown to diminish
skin perfusion.17 This imposition results in a reduction
of the thermoregulatory effects of sweat evaporation in
addition to the insulating properties of the garment. While
the elevated muscle temperature induced by compression
clothing might be positive for recovery purposes, the rise
in muscle temperature beyond optimal may inhibit perfor-
mance during endurance exercise in hot environments.7,8
However, 2 of 3 included studies on compression cloth-
ing assessed in this review were performed in moderate
environmental conditions (15–18°C).33,36 Under these
conditions, the reduction in evaporation is suggested to
be less important while there is an increased reliance on
conduction, as well as convection, which does not result
in impaired performance.39 So far, no study has investi-
gated the effect of compression clothing in winter sports.
Since the reduction in skin blood ow would increase
blood volume in the working muscles, compression might
especially serve as an ergogenic aid in performance in
cold environmental conditions. Therefore, compression
clothing can be applied with cognizance of the underly-
ing atmospheric conditions and duration of the exercise.
Practical Application and
Conclusion
Based on our ES calculations summarizing the ndings
of 31 studies independent of statistical signicance,
compression clothing promotes numerous physiological
processes capable of assisting athletic performance and
subsequent recovery. However, in some cases there is

16 Born, Sperlich, and Holmberg
little evidence to support some of the purported benets,
and gaps in knowledge are still evident. The magnitude of
the effects should also be taken into account when assess-
ing the meaningfulness and practical relevance of the use
of compression clothing in a given situation. Based on
our ES calculation, we conclude that there are benecial
effects of compression clothing, especially during inter-
mittent high-intensity exercise such as repeated sprinting
and jumping, rather than during submaximal endurance
exercise. Furthermore, the benefits of compression
clothing seem to be most pronounced when it is applied
for recovery purposes 12 to 48 hours after signicant
amounts of muscle-damage-inducing exercise.
Most of the reviewed studies applied lower body
compression (ie, knee-high socks, shorts, or tights) with
and without distal-to-proximal pressure gradient for
performance enhancement. Based on our ndings, we
conclude that the application of compression clothing
during exercise has small effects on improving short-
duration sprints (10–60 m), vertical-jump height, and
time to exhaustion (such as running at VO2max or during
incremental tests), as well as time-trial performance
(3–60 min). The use of upper body compression may be
of practical relevance to support upper body exercise;
however, further research is warranted on this topic. Since
several sports regulate their athletes’ competition outt,
we recommend the application of lower and upper body
compression according to the regulations, nature of sport,
and environmental conditions.
If compression clothing is worn for recovery pur-
poses 12 to 48 hours after exercise, we conclude small or
moderate effects for recovery after maximal strength and
power, particularly vertical-jump exercise; reductions in
muscle swelling and perceived muscle pain; and blood
lactate removal. Large effects are evident for increased
body temperature.
Acknowledgments
The authors declare no conicts of interest that are directly
related to this article. For the preparation of this article, no
sources of funding were used for assistance.
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