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REVIEW
Effects of Wearing Compression Stockings on
Exercise Performance and Associated Indicators:
A Systematic Review
This article was published in the following Dove Press journal:
Open Access Journal of Sports Medicine
Gustavo R Mota
1
Mário Antônio de Moura
Simim
2
Izabela Aparecida dos Santos
1
Jeffer Eidi Sasaki
1
Moacir Marocolo
3
1
Human Performance and Sport
Research Group, Department of Sport
Sciences, Institute of Health Sciences,
Federal University of Triangulo Mineiro,
Uberaba, MG, Brazil;
2
Research Group in
Biodynamic Human Movement, Institute
of Physical Education and Sports, Federal
University of Ceará, Fortaleza, CE, Brazil;
3
Physiology and Human Performance
Research Group, Department of
Physiology, Federal University of Juiz de
Fora, Juiz de Fora, MG, Brazil
Abstract: This systematic review investigated the effects of wearing below-knee compres-
sion stockings (CS) on exercise performance (or sports activity) and associated physiological
and perceived indicators. We searched articles on PubMed using the following terms:
“graduated compression stockings”;“compression stockings”;“graduated compression
socks”;“compression socks”combined with “performance”,“athletes”,“exercise”,“exercise
performance”,“fatigue”,“sports”and “recovery”, resulting in 1067 papers. After checking
for inclusion criteria (e.g., original studies, healthy subjects, performance analysis), 21
studies were selected and analyzed. We conclude that wearing CS during exercise improved
performance in a small number of studies. However, wearing CS could benefit muscle
function indicators and perceived muscle soreness during the recovery period. Future
research should investigate the chronic effect of CS on Sports Medicine and athletic
performance.
Keywords: ergogenic aid, fatigue, sports, medicine, prevention, soccer, running
Introduction
The prevention of deep venous thrombosis is one of the first evidence-based
benefits of wearing compression stockings (CS), demonstrated by a clinical experi-
ment in which CS improved the venous return by increasing femoral vein blood
flow velocity in hospitalized patients.
1
Over time, the interest from the basic
medical area has expanded to other fields like Sports Medicine.
2
Nowadays,
recreational and professional athletes have used CS as a tool for improving perfor-
mance or accelerate recovery from training or competitions, and also to reduce
lower limb volume,
3,4
relieve symptoms of muscle soreness, and fatigue.
3–6
Such
popularity is probably boosted by the possibility to obtain potential ergogenic
benefits with a simple and low-cost aid.
There are different types (e.g., shorts for thighs, full-leg) and application modes
(e.g., using only after the exercise) for compression garments. However, using CS
(bellow-knee) “only during”the exercise are probably more practical (than during
recovery, after-exercise) for a significant number of sports/activities. For example,
uniform issues would limit whole-body garments in some sports. Also, athletes living
in tropical locations could be unmotivated to wear compression garments after
training sessions once those garments usually promote higher skin temperatures.
7,8
Additionally, there is limited evidence regarding the effects of wearing CS (only)
Correspondence: Gustavo R Mota
Human Performance and Sport Research
Group, Department of Sport Sciences/
Institute of Health Sciences, Federal
University of Triângulo Mineiro, Av.
Tutunas, 490 Uberaba/MG, Uberaba
38061-500, Brazil
Tel +55 34 3700-6633
Email grmotta@gmail.com
Open Access Journal of Sports Medicine Dovepress
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during exercise/training/competition, which could be rele-
vant for Sports Medicine professionals. Therefore, the pur-
pose of this systematic review was to investigate the effect
of wearing below-knee CS during exercise (or sports activ-
ity) on performance and associated physiological and per-
ceptual indicators.
Methods
A systematic literature search was performed by two inde-
pendent reviewers in PubMed. The following terms: (i)
“graduated compression stockings”; (ii) “compression
stockings”; (iii) “graduated compression socks”; (iv)
“compression socks”were combined with “performance”,
“athletes”,“exercise”,“exercise performance”,“fatigue”,
“sports”and “recovery”(Figure 1).
Inclusion Criteria
The studies included in this review met the following inclu-
sion criteria: 1) original studies; 2) comprised samples of
adults (≥18 yr); 3) participants were healthy; 4) investi-
gated the effects of wearing foot-to-knee (below knee) CS
(during exercise) on exercise performance and physiologi-
cal and perceptual indicators (e.g., muscle fatigue, muscle
recovery, musle soreness); 5) compression stockings worn
during the exercise/test/match; and 6) study protocol
included exercise or effort tests and performance analysis.
The literature search occurred between January 01,
1900, until June 30, 2019. We excluded the following
type of articles: conference abstracts, case reports, short
communications, systematic reviews, meta-analyses, the-
ses, letters to the editor, and protocol papers. Also, we
excluded studies involving unhealthy participants: e.g.,
patients with morbid conditions such as obesity, chronic
venous insufficiency, diabetes, hypertension (but not lim-
ited to).
Analysis
The heterogeneity of the selected studies was consider-
able: e.g., exercise protocols, fitness level of the partici-
pants, variables measured. Thus, we have decided not to
evaluate the studies chosen from a statistical point of view.
Instead, we performed a qualitative analysis, conducted by
two authors focusing on the effects reported by the authors
and potential practical implications. All other authors read
this qualitative analysis carefully, and edits have been
incorporated.
Results
Figure 1 shows the search, selection, and inclusion pro-
cess. The search displayed a total of 1067 papers, which
were reduced to 370 after exclusion of duplicate publica-
tions. Then, we discarded 39 articles written in non-
English languages.
9
From the remaining 331 items, we
excluded 261 by examining the title. Finally, from the
remaining 70 articles, we selected 21 studies for this
review according to our inclusion criteria (Figure 1).
Table 1 presents a summary of the studies examining
the effects of wearing below-knee CS during exercise on
performance and associated indicators. Running was the
most common type of exercise in the selected studies
(76%, 16 out of the 21 studies), followed by soccer (two
studies; 10%), triathlon, calf-rise exercise and cycle erg-
ometer (one study each one; 5%). All studies were per-
formed using a randomized experimental design, with the
majority employing a crossover design strategy (13 stu-
dies, 62%) (Table 1).
Table 2 presents those studies in which CS influenced
at least one measurable variable (15 studies, 71%). Three
studies (14%) found effects from wearing CS on at least
two variables, and for all others (12 studies; 57%) CS
affected only one variable (Table 2).
Only two studies found some beneficial effect of CS
on performance, and a third study improved subsequent
performance (Table 2). Two studies did not find per-
formance effects of CS for the group mean, but the
authors highlighted that CS promoted benefits for some
individuals. The main effects of CS are presented with
compressions between 20 and 30 mmHg. The range
between the minimum compression values is 12 to
28 mmHg, while the maximum values range from 15
to 33 mmHg.
Discussion
This systematic review aimed to investigate the effect of
wearing below-knee CS during exercise on performance
and associated indicators. The main finding is that wearing
this kind of CS during exercise (or physical activity)
improved performance in a minor part of the studies
selected (i.e., 3 out of 21). However, a reasonable number
of studies have shown evidence that wearing CS could
benefit muscle function or fatigue indicators (e.g., CMJ,
specific physical tests) and perceived muscle soreness just
after the exercise protocol and/or hours after the exercise
bout (e.g., during 1 h, 24 h recovery).
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CS and Performance Improvement
One of the main reasons for wearing CS during exercise
is probably the expectation of performance enhancement
due to potential physiological effects.
2
This includes
better venous return which hasten metabolic removal
from the exercising muscles
31
and reduce cardiac
load,
26
improved proprioceptive feedback and better
movement accuracy,
32
reduced muscle oscillations,
lower muscle damage, inflammation, and soreness.
6,31
In the current review, only three studies found some
CS-induced benefit on performance but did not present
adirect mechanistic explanation. For example, astudy
concluded that wearing CS (during two soccer matches,
72 hin-between) resulted in higher distances covered in
high-intensity activities which are decisive for soccer.
Also, CS promoted alower perceived muscle soreness in
thesecond match.
17
Although the authors did not mea-
sure any direct muscle damage marker, they suggested
that CS probably protected the eccentric actions com-
mon in soccer matches,
33
mechanically (i.e., smaller
muscle oscillation).
6
In this regard, the oscillating forces
experienced by the muscle resulted in reduced muscle
fatigue. Thus, the CS might offer a mechanical advan-
tage reducing muscle oscillation and countering fatigue
in high-intensity activities (e.g., intermittent accelera-
tion, changing directions).
34,35
Figure 1 Flow chart for search and selection of articles.
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Table 1 Characteristics of the Studies Examining the Effects of Wearing CS Below-Knee During the Exercise Performance and Related Indicators
Date-Author Subjects Age Aim Experimental
Design
CP (mmHg) Type of
Exercise
Exercise Protocol/
Details
Findings
Ali et al 2007
10
(Experiment 1)
14
recreational
runners (men)
22±0.4 To examine the influence of
wearing graduated CS on
physiological and Perceptual
responses during and after
exercise
Randomized
crossover
18–22 Intermittent
running
2 x multi-stage fitness
shuttle running test,
with 1 h recovery
between tests
CS had no effects on distance
covered, HR, perceived soreness,
RPE and comfort
Experiment 2 10 individuals
participated in
both
experiments
23±0.5 Randomized
crossover
18–22 Continuous
running
10 km time-trial CS decreased muscle soreness 24
h after the 10 km, but not
performance, HR, RPE
Ali et al 2011
11
12 well-
trained
runners (men
and women)
33±10 To examine the effects of
wearing different grades of CS
on 10 km running
performance and to assess the
effects on physiological and
perceptual responses after
exercise
Randomized
crossover
Control - 0
Low 12–15
Med 18–21
Hi 23–32
Running 10 km time-trial CS worn did not affect
performance; Low and Med CS
resulted in greater maintenance of
leg power after 10 km
Areces et al
2015
12
34
experienced
runners (30
men and 4
women)
42±7.8
control
41.2±8.9
CS
To investigate the benefits of
CS for running pace,
prevention of muscle damage,
and maintenance of muscle
performance during a real
marathon
Randomized
Controlled trial
20–25 Running Marathon race
(42,195 m)
CS did not improve marathon race
time, muscle function, RPE or
markers of muscle damage
Berry et al
1987
13
6 high fit men
college
students
22.5±5.4 To determine the effects of CS
on maximal oxygen
consumption, time to
exhaustion, and blood lactate
during recovery
Randomized
crossover
8–18 Running Incremental treadmill
test until exhaustion
CS had no effect on VO2max,
recovery of VO2max. Blood lactate
was lower on recovery period
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Bieuzen et al
2014
14
11 highly
trained men
runners
34.7±9.8 To examine the effect of
wearing CS on indices of
exercise-induced muscle
damage in a trail-running
context
Randomized
crossover
25 Running
(simulated
trail race)
15.6 km total
distance, being 3 laps
of 5.2 km
In mountainous
terrain. Each lap had
a climbing (2.2 km, ~
13%)
Followed by
a downhill (3 km, ~ –
9%).
CS improved post-exercise
recovery (perceived leg soreness
and muscle function); No benefits
on markers of muscle damage/
inflammation
Brophy-
Williams et al
2019
15
12 well-
trained men
runners
30.5±8.1 To assess the effect of wearing
CS during a 5 km running
time-trial on physiological,
perceptual and performance-
based parameters, and
subsequent performance
Counter-
balanced
crossover
experiment
37 ± 4 mmHg at
the maximal calf
girth, 31 ± 4
mmHg at the
upper ankle and 23
± 4 mmHg at the
lower ankle
Running Maximal 5 km time-
trial on treadmill (CS
or control).
A subsequent 5 km
time-trial was
performed 60 min
later (without CS)
CS did not affect immediate
performance, but had a positive
impact on subsequent performance
(less decrement from first to
the second 5 km time-trial)
Del Coso et al
2014
16
36
experienced
triathletes
35.8±6.3
control
35.0±5.3
CS
To investigate the effects CS
to prevent muscular damage
and to preserve muscular
performance during a half-
ironman competition
Matched for
age,
anthropometric
And training
status and
randomly
assigned to CS
or control
Not mentioned Half-
ironman
Triathlon
Half-ironman
Triathlon competition
(1.9 km of swimming,
75 km of cycling and
21.1 km of running)
CS did not improve performance,
and did not prevent the reduction
in lower-limb muscle function, as
well as did not reduce post-race
muscle damage markers
Gimenes et al
2019
17
20 under-20
soccer players
(men)
18.3±0.5
control
To evaluated the effects of
using CS on the match-based
physical performance
indicators, HR and perceptual
responses during 2 matches
Randomized
(balanced by the
playing position)
20–30 Soccer
matches
Two soccer matches
separated by 72 h
CS minimized the increment of
local muscle soreness in the 2nd
match; promoted higher distance
covered in high-intensity activities
18.4±0.4
CS
(Continued)
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Table 1 (Continued).
Date-Author Subjects Age Aim Experimental
Design
CP (mmHg) Type of
Exercise
Exercise Protocol/
Details
Findings
Kemmler et al
2009
18
21
moderately
trained men
runners
39.3
±10.7
To determine the effect of CS
on parameters of running
performance
Randomized
crossover
24 Running Stepwise
Speed-incremented
treadmill test to
voluntary maximum
(every 5 min, speed
was increased)
CS improved running performance
at various metabolic stages: total
work and time under load**,
maximum speed, parameters at the
anaerobic thresholds
Menetrier et al
2011
19
14 moderatey
trained
athletes
21.9±0.7 To determine the effects of
calf compression sleeves on
running performance and on
calf tissue oxygen saturation
(sto2) at rest before exercise
and during recovery period.
Randomized
crossover
18–30 Running Running time to
exhaustion
CS did not improve times to
exhaustion performed; However,
the StO2 results argue for further
interest of this garment during
effort recovery.
Miyamoto et al
2011
20
14 healthy
men
25.6±3.7 To examine the effects of
wearing a CS, with different
pressure profiles during
a fatiguing calf-raise exercise
session, on the torque
generating capacity after
exercise.
Randomized
crossover
18 and 30 Calf-raise
exercise
15 sets of 10
repetitions of calf-
raise exercise - 30
s rest between sets
CS with adequate pressure at the
calf region relieves muscle fatigue of
the triceps surae induced by calf-
raise exercise.
Pavin et al
2019
21
20 amateur
female soccer
players
20.6±3.9 To evaluate the effect of CS
use during an amateur female
soccer match on match-
induced fatigue indicators
Randomized
(balanced by the
playing position)
20–30 Soccer
match
A single soccer match CS positively influenced agility and
lower limb muscular endurance
(standing heel-rise) performances
following the match
Rider et al
2014
22
10 cross-
country
runners (men
and women)
Men 21
±1.3
Women
18.7±0.6
To determine the effect of CS
on physiological variables
associated with running
performance
Randomized
Crossover
15–22 Running Maximal treadmill
test
CS did not improve running
performance, but could lend
credence to certain manufacturers
claims of improved recovery
through lower BLa values after
exercise
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Rimaud et al
2010
23
8 healthy
trained males
21.7±0.9 To investigate if wearing CS
during exercise and recovery
could affect lactate profile in
sportsmen
Randomized
crossover
12–22 Cycle
ergometer
Incremental cycle
ergometer test
CS during graded exercise lead to
a significant higher blood lactate
value at exhaustion, probably due
to a higher lactate accumulation
related to a greater overall
contribution of anaerobic glycolysis
in the energy supply when subjects
wore CS during exercise
Sperlich et al
2010
24
15 well-
trained
endurance
athletes
27.1±4.8 To test three types of
compression clothing on well-
trained athletes to assess
physiological responses and
effects on performance
Randomized
crossover
20 Running Incremental test in
treadmill
CS did not improved time to
exhaustion or resulted in any
altered oxygen uptake response,
lactate concentration, or ratings of
perceived exertion and muscle
soreness during maximal and
submaximal exercise
Treseler et al
2016
25
19
recreationally
active women
20±1 To examine the physiological
and perceptual responses to
wearing below-the-knee CS
after a 5-km running
performance
Randomized
crossover
12.6–21 Continuous
running
5 km time-trial CS had no effects on 5 km time and
HR, but resulted in less muscle
soreness in lower extremities and
higher RPE
Varela-Sanz
et al 2011
26
(Experiment 1)
16 endurance
trained
athletes (men
and women)
34.7± 6.3 To examine the effect of
gradual-elastic compression
stock- ings (gcss) on running
economy
Randomized
repeated-
measures design
15–22 Continuous
running
4 bouts of 6-min half-
marathon pace
treadmill running
CS had no effects on running
economy and RPE
Experiment 2 12 endurance
trained
athletes (men
and women)
*These
individuals
also
participated in
experiment 1
Not
described
To examine the effect of gcss
on kinematics, and running
performance
Randomized
non–crossover
design
15–22 Continuous
running
Treadmill running
until exhaustion at
105% of the athlete’s
recent 10-km time
and 1% grade
CS resulted in lower %HR
max
.No
effects of the CS were observed for
time to fatigue, HR
peak
, lactate, RPE,
VO
2 peak
, speed, %VO
2 max
, and RE
(Continued)
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Table 1 (Continued).
Date-Author Subjects Age Aim Experimental
Design
CP (mmHg) Type of
Exercise
Exercise Protocol/
Details
Findings
Vercruyssen
et al 2012
27
11 male
trained
runners
34.7±9.8 To investigate the effects of CS
on performance indicators and
physiological responses during
prolonged trail running
Randomized
crossover
18 Continuous
running
15.6 km trail-running CS had no effects on run time, HR,
blood lactate concentration and
RPE
Wahl et al
2012
28
9 well-trained,
male
endurance
athletes
22.2±1.3 To test if different levels of
sock compression affect
erythrocyte deformability and
metabolic parameters during
sub-maximal and maximal
running
Randomized
repeated-
measures design
0, 10, 20, and 40 Continuous
running
30 min sub-maximal
running and time to
exhaustion thereafter
using a ramp test
(increase in incline of
1% every minute)
CS had no effects on erythrocyte
deformability, heart rate, pO2 and
lactate concentration. However,
exercise itself significantly increased
erythrocyte deformability, with high
CS attenuating this effect.
Zadow et al
2018
29
67 marathon
runners (men
and women)
46.7
±10.3
To investigate the effect of
wearing compression socks on
coagulation and fibrinolysis
following a marathon
Randomized
controlled trial
Not described Continuous
running
Marathon race
(42,195 m)
CS significantly reduced post-
marathon D-Dimer concentrations
Zaleski et al
2018
30
20 runners
(men and
women)
Control:
35.5±8.0
CS: 36.9
±8.4
To examine the influence of
CS worn during a marathon
on creatine kinase levels
Randomized
controlled trial
19–25 Continuous
running
Marathon race
(42,195 m)
CS had no effects on CK levels at
baseline, immediately following, or
24h after a marathon race.
Notes: **Time under load means the maximal amount of minutes performed at a submaximal speed (i.e., 9 to 11 km.h
−1
) to ensure over 30 mins running.
Abbreviations: CP, compression pressure; CMJ, countermovement jumps; CK, creatine kinase; CS, compression stockings; ES Cohen’s d, effect size; RPE, rating of perceived exertion.
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Table 2 Studies That Found Effects from Wearing CS During Exercise
Study Potential
Benefited Variable
Summary Effects from CS No Effects from CS
Ali et al 2007
10
Muscle soreness
Experiment 2: CS decreased
muscle soreness following each
exercise bout, and 24 h after the
10 km time-trial;
Performance was not influence by
CS (P=0.15)
Experiment 2:
Lower perceived muscle soreness
potential Individual improvements:
10 of the 14 Participants ran faster
~20s
Experiment 1:
Distance covered on the multi-stage fitness Shuttle running
test
HRmean
Perceived muscle soreness
RPE
Experiment 2:
Time to complete 10 km time-trial (mean)
Time to complete 1st and 2nd 5 km partial time RPE
Ali et al 2011
11
Muscle fatigue
CS worn (low and medium
compression) resulted in greater
maintenance of leg power after
10 km, but performance on 10 km
did not
Vertical jump height higher (from
pre-to post-10 km running) when
wearing Low (12–15 mm Hg) and
Med (18–21 mm Hg) CS
Time to complete 10 km
RPE
HRmean
High (23–32 mm Hg) CS hadno benefit for vertical jump post-
10 km
Berry et al 1987
13
Lactate recovery
CS did not affect the VO2max,
recovery of VO2max, but blood
lactate was lower on the recovery
period when CS was worn during
incremental treadmill test until
exhaustion
Lower blood lactate after the
incremental test (at 15 min of the
recovery period)
VO2max
Time to exhaustion
recovery of VO2max
Bieuzen et al 2014
14
Muscle soreness
Muscle fatigue-recovery
CS improved post-exercise
recovery (perceived leg soreness
and muscle function); CS did not
influence the performance
(15.6 km in mountainous terrain)
and markers of muscle damage/
inflammation
Lower perceived muscle soreness
Higher isometric peak torque and
MVC (knee extensors) at 1 h (ES
small) and 24 h post-run
All recovery periods on CMJ (ES
large)
Time to complete 15.6 km
RPE
HR responses
CK and interleukin-6 levels
Brophy-Williams et al
2019
15
Subsequent performance
CS did not affect immediate
performance, but had a positive
impact on subsequent performance
(1 h later)
Lower decrement from TT1 to
TT2 (~9.5 s vs control) on time to
complete 5 km
Time to complete TT1 (5 km)
Time to complete TT2 (5 km)
Oxygen consumption
Blood lactate
Cross sectional area of calf
RPE
Perceived muscle soreness
Perceived fatigue
Perceived recovery
Gimenes et al 2019
17
Muscle soreness
Acute performance
CS minimized the increment of
local muscle soreness in the 2nd
match (two soccer matches with
72 h in-between); CS also
improved performance in high-
intensity activities during the
matches
Minimized the increment of
muscle soreness on match 2;
Higher distances covered >
19.1 km.h
1
and ≥23 km.h
−1
on
match 1 higher distances covered
between 19.1 and 22.99 km.h
−1
on
match 2
Match 1
Perceived soreness and recovery
RPE
HRmean, HRpeak
Internal load (RPE x minutes played)
Sprints repetitions
Distances covered in total and below 19.1 km.h
−1
Match 2
Perceived recovery
RPE
HRmean, HRpeak
Internal load (RPE x minutes played)
Sprints repetitions
Distances covered in total and below 19.1 km.h
−1
(Continued)
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Table 2 (Continued).
Study Potential
Benefited Variable
Summary Effects from CS No Effects from CS
Kemmler et al 2009
18
Acute performance
Anaerobic threshold
CS improved running
performance and metabolic
indicators (anaerobic threshold)
Time under load** (ES 0.40)
Total work (ES: 0.30)
Running at the anaerobic (ES:
0.22)
And aerobic thresholds (ES: 0.28)
VO2max
Maximal lactate concentration
HRmax
Pulmonary ventilation
Ventilator equivalent
Respiratory exchange ratio
Menetrier et al 2011
19
Oxygen saturation at
recovery
CS did not improve performance,
however CS increased calf tissue
oxygen saturation at rest and
during recovery from exercise
Increased calf tissue oxygen
saturation at rest (before
exercise): + 6.4±1.9%
And during recovery: + 7.4±1.7%
and + 10.7 ± 1.8% at 20th
And 30th min of the last recovery
period, respectively
Times to exhaustion performed
HRmean
HRmax
RPE
Miyamoto et al 2011
20
Muscle fatigue
CS had no effect on the decline of
MVC, but the extent of reduction
of the evoked triplet torque was
smaller when wearing CS with
a high compression pressure
The decline of the MPF in the CS
30 mmHg was significantly smaller
than that in 0 mmHg (control)
Reduction of the MVC torque after the ca lf-raise amon g 0
(control), 18 and 30 mmHg CS
EMG amplitude during the MVC was decreased, the
extent to which was not significantly different among the
three
Conditions bot h for the medial gastrocnemius and soleus
M-wave amplitude (evoked co ntraction)
Pavin et al 2019
21
Muscle fatigue
CS positively influenced agility and
lower limb muscular endurance
performances following a soccer
match
After-match kept the time to
complete T-test Agility (control
performed slower) from baseline
Control presented greater
decrement after-match (ES = 1.27
control vs. CS) in the heel-rise
test repetitions from baseline
Distance covered in the Yo-Yo intermittent endurance level
2 after match
HRmean, peak and %peak
RPE
Rider et al 2014
22
**worst acute performance
Lactate recovery
CS did not improve running
performance, but seem to
improve recovery after exercise
Time to fatigue lower in CS
(**negative)
Blood lactate lower during
recovery (1 and 5 min)
HR
blood lactate (during the maximal treadmill test)
lactate threshold
VO2max
Respiratory exchange ratio
RPE
Rimaud et al 2010
23
Lactate recovery
CS did not improve performance
during graded maximal exercise
but lead to a higher contribution
of anaerobic glycolysis and
improved lactate removal during
passive recovery. However, CS
efficacy is highly limited
Higher blood lactate value at
exhaustion
Lactate removal ability was
improved (during passive
recovery)
Submaximal/maximal HR
VO2
Performance (W on VO2max)
SBP
RPE
Treseler et al 2016
25
Muscle soreness
CS decreased muscle soreness (24
h post-run) in lower extremities,
(but not for calf) and presented
higher RPE (feelings of working
harder with CS); CS did not
influence 5 km performance
(P=0.74)
Lower perceived muscle soreness
24 h later
Potential individual improvement
(10 of 19 participants ran faster
~10 s)
Time to complete 5 km time-trial (mean)
HR responses
Rate of perceived recovery
(Continued)
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Another study showed CS-induced ergogenic effects
on performance. The authors found an improvement in
running performance concomitantly with anaerobic and
aerobic thresholds when participants wore CS.
18
The ben-
efits of CS-ergogenic effects on performance are attributed
to enhanced biomechanical support of the muscles, leading
to higher efficiency and lower metabolic costs at given
workloads,
18,36
reduction of muscular microtrauma,
6
and
enhanced the proprioception.
32
During a 5 km running
time-trial (Brophy-Williams et al
15
) the wearing CS did
not affect immediate performance. However, CS generated
a positive impact on subsequent 5 km running (i.e., less
performance decrement from time-trial 1 to time-trial 2).
Again, the underlying mechanism of such benefitis
unclear but may be related to increased oxygen delivery,
lower muscle oscillation, and better running mechanics.
15
Despite the current results, the literature does not indi-
cate robust evidence favoring the use of CS during exercise
(i.e., only three studies found benefits on performance).
Researchers should be careful in drawing conclusions.
Considering that each specific study has (or had)
a particular experimental design (e.g., exercise protocol,
duration, intensity, variables measured, fitness level of the
participants), it becomes difficult to generalize the results
from the different studies. Thus, it is essential to consider
the risk of bias and heterogeneity of the studies. As the
same protocol does not conduct different studies, they will
vary in the characteristics of the included population, inter-
ventions, diagnostic methods to access outcomes, etc. (clin-
ical heterogeneity). Thus, these studies may be biased.
37
Additionally, two studies did not find CS-induced effects
on group mean performance, but the authors highlighted the
individual improvements: 10 of 19 runners ran the 5 km
time-trial approximately 10 s faster,
25
and10ofthe14
runners ran the 10 km time-trial
10
approximately
20 s faster. Therefore, individual responses should be care-
fully evaluated in practical settings.
CS, Muscle Function and Perceived
Muscle Soreness
Some studies in the current review have shown that CS can
induce lower muscle fatigue after an exercise protocol with
the same workload than a control condition.
11,14,20,21
The
lower after-exercise fatigue may suggest a preserved muscle
function. Overall, such studies show the maintenance (based
on baseline values) of muscle function by a smaller decre-
ment of performance (or none) in specific muscular tests
performed after the exercise protocol (e.g., running time-
trial, soccer match). On the same reasoning, the lower per-
ceived muscle soreness found in the current review is also
a potential beneficial outcome from CS. The smaller muscle
soreness may be particularly relevant for more prolonged
periods with multiples exhausting physical activities per-
formed with a short recovery period in-between.
17
In one of the studies, competitive runners (VO
2
max
~69 mL.kg.min) completed four 10 km time-trial wearing
control CS (0 mm Hg) and CS with different pressures in
a randomized, counterbalanced order.
11
The runners per-
formed CMJ tests before and after running as a muscle func-
tion indicator. The results showed that CMJ height decreased
after control running. However, CMJ performance was
improved after running wearing CS (low and medium pres-
sure), suggesting a better maintainance of muscle function.
Table 2 (Continued).
Study Potential
Benefited Variable
Summary Effects from CS No Effects from CS
Varela-Sanz et al 2011
26
(experiment 2)
Acute lower cardiac stress
CS resulted in lower cardiac
stress during a test at competition
pace, but none effects for
performance and other
physiological and perceptual
indicators
Lower HR response during a test
at competition pace (ie, 105% best
10 km run)
Time to fatigue
HR
peak
Blood lactate
RPE
VO
2 peak
speed
%VO
2 max
Running economy
Zadow et al 2018
29
Lower fibrinolytic activity
CS significantly reduced post-
marathon fibrinolytic activity
Lower D-Dimer concentrations
post-marathon
Marathon finishing times
Thrombin–anti-thrombin complex tissue factor
Tissue factor pathway inhibitor
Notes: **Time under load means the maximal amount of minutes performed at a submaximal speed (ie, 9 to 11 km.h
−1
) to ensure over 30 mins running.
Abbreviations: CMJ, countermovement jumps; CS, compression stockings; ES Cohen’s d, effect size; HR, heart rate; MVC, maximal voluntary contraction; RPE, rating of
perceived exertion; TT, time-trial.
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The authors speculated that improvements in proprioception
to jump and reduced muscle oscillations due to CS probably
collaborated with lower muscle fatigue.
11
In other included study, highly trained runners partici-
pated in 3 simulated trail races (15.6 km, including uphill
and downhill) in a randomized crossover trial.
14
Authors
measured indicators of muscle function (and also muscle
perceived soreness) at baseline, 1, 24, and 48 h after-run.
Muscle function decreased after the race, suggesting the
appearance of fatigue, which was partially counteracted by
CS. More specifically, a beneficial effect from wearing CS
was found for isometric peak torque at 1 h and 24 h post-
run and for CMJ throughout the 48 h recovery period.
Perceived muscle soreness was also lower when runners
wore CS during trail running compared with the control
condition (1 h and 24 h post-run). Specific muscle con-
tractions during trail running (e.g., eccentric on the down-
hill portion) might result in more extensive muscle
oscillation and soreness. Thus, CS probably reduced the
perceived muscle soreness due to the higher preservation
of muscle function.
14
Miyamoto et al
20
showed that CS promoted a smaller
extent of reduction (- 6.4 ± 8.5% for CS vs. −16.5 ± 9.0%
for control) of the evoked triplet torque, after a fatiguing
protocol (15 sets X 10 repetitions) of calf-raise exercise.
The authors suggested that mitigation of muscle fatigue
observed in their study could be related to increased
venous flow velocity and prevention of the lowering of
the intramuscular pH.
20
Positive CS-induced benefits on muscle fatigue was also
described after a soccer match. Female players of both
teams (50% each team, randomly wore CS or control
socks) performed tests (agility T, standing heel-rise, and
YoYo Intermittent Endurance II) 48 h before (baseline)
and immediately after the game. CS resulted in less match-
induced fatigue for agility T-test performance (maintenance
for CS and decrement in control players) and heel-rise test
(both groups had a decrement on the number of repetitions,
but higher in control).
21
In the current review, some researchers found
a beneficial CS-effect on the perceived muscle soreness
in lower extremities after the following exercises: high-
intensity continuous 10 km road-running,
10
15.6 km trail
in mountainous terrain,
14
in the second match of soccer
(72 h between the first game),
17
and 24 h post 5 km time-
trial.
25
Overall, those studies suggested a lower perception
of muscle soreness due to less extensive muscle damage
(lower muscle oscillation), and better proprioception.
However, we cannot rule out a potential placebo effect,
once it is hard to control such bias due to the nature of
compressive CS versus control socks.
CS, Other Potential Benefits, and Final
Considerations
Besides performance, muscle soreness, and muscle function
indicators, 15 out of the 21 studies selected in this review
presented other variables influenced by CS: lower blood
lactate levels,
13,22,23
and fibrinolytic activity,
29
higher oxy-
gen saturation,
19
after the exercise protocol (recovery).
Also, lower cardiac stress during exercise has been found.
26
Mitigation of exercise-induced muscle damage is
a possible effect according to authors that found benefit
from wearing CS in this review. However, none of them
measured blood markers of muscle damage (e.g., creatine
kinase - CK, lactate dehydrogenase - LDH). Curiously, only
three studies measured such markers after-exercise:
amarathonrace,
12
a 15.6 km trail-running,
14
and half-
ironman triathlon competition,
16
and found no effect from
CS. The lack of measurements of muscle damage markers on
several studies herein included may be due to the experimen-
tal design and the fact of “only”wearing the CS during the
exercise (i.e., more focus on performance than recovery).
Longer time-points of measurement after the activity (e.g.,
time-course of CK for at least 24 h after-exercise) could be
necessary to detect a significant change in CK,
38
for example.
Finally, we highlight that in a real-world scenario, ath-
letes probably will not use a promising ergogenic aid to
improve performance (e.g., CS) only once, as the majority
of studies included here. Athletes would perhaps try it in
a couple of training session and one competition before to
make a final decision. Also, in practical terms, athletes
usually may combine different strategies to improve perfor-
mance and later recovery, such as ischemic
preconditioning,
39,40
myofascial release, and cold water
immersion.
41
Currently, the effects of such strategies (iso-
lated or combined) with CS are unknown. Therefore, the
interpretation of our findings should have in mind “to see
also the forest, not just the leaf”.
Conclusions
Wearing below-knee CS during exercise (or sport/physical
activity) improved the actual performance in a small number
of the studies analyzed. However, there is some evidence that
wearing CS could benefit muscle fatigue indicators and mus-
cle soreness immediately after and hours after an exercise
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bout (e.g., better recovery until 48 h). Lower muscle fatigue
and muscle soreness might be helpful in subsequent exercises
or more extended periods of intervention (e.g., several
months). Thus, Sports Medicine professionals should con-
sider the individual responses for performance and
a potential placebo (or nocebo) effect. Future studies should
evaluate longer experimental designs (e.g., several weeks)
wearing CS on exercise performance and physiological indi-
cators, once the chronic effects are unknown.
Disclosure
The authors report no conflicts of interest in this work.
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