Available via license: CC BY-NC 4.0
Content may be subject to copyright.
DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614 1
Open access Original research
Effect of sports massage on performance
and recovery: a systematic review
and meta- analysis
Holly Louisa Davis, Samer Alabed, Timothy James Ainsley Chico
To cite: DavisHL, AlabedS,
ChicoTJA. Effect of sports
massage on performance and
recovery: a systematic review
and meta- analysis. BMJ Open
Sport & Exercise Medicine
2020;6:e000614. doi:10.1136/
bmjsem-2019-000614
Accepted 6 April 2020
Correspondence to
Dr Timothy James Ainsley
Chico, Infection, Immunity
and Cardiovascular Disease,
University of Shefeld, Shefeld,
South Yorkshire, UK;
t. j. chico@ shefeld. ac. uk
© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
Summary box
What is already known
►A previous smaller meta- analysis found that mas-
sage gave small and inconsistent improvements in
performance recovery.
►A previous smaller meta- analysis found that mas-
sage gave no signicant improvement in pain or de-
layed onset muscle soreness (DOMS).
►Previous studies have shown inconsistent effects of
massage on exibility.
What are the new ndings
►Our larger meta- analysis nds that massage in-
duces no signicant improvement in measures of
performance (sprint, jump, strength, endurance or
exibility, or in fatigue)
►Our larger meta- analysis nds that massage pro-
vides a small benet in reducing or preventing
DOMS.
►Our meta- analysis shows massage induces a small
but signicant improvement in exibility compared
with no intervention.
ABSTRACT
Objective Massage is ubiquitous in elite sport and
increasingly common at amateur level but the evidence
base for this intervention has not been reviewed
systematically. We therefore performed a systematic
review and meta- analysis examining the effect of massage
on measures of sporting performance and recovery.
Design and eligibility We searched PubMed, MEDLINE
and Cochrane to identify randomised studies that tested
the effect of manual massage on measures of sporting
performance and/or recovery. We performed separate
meta- analyses on the endpoints of; strength, jump, sprint,
endurance, exibility, fatigue and delayed onset muscle
soreness (DOMS).
Results We identied 29 eligible studies recruiting 1012
participants, representing the largest examination of the
effects of massage. We found no evidence that massage
improves measures of strength, jump, sprint, endurance
or fatigue, but massage was associated with small but
statistically signicant improvements in exibility and
DOMS.
Conclusion Although our study nds no evidence that
sports massage improves performance directly, it may
somewhat improve exibility and DOMS. Our ndings help
guide the coach and athlete about the benets of massage
and inform decisions about incorporating this into training
and competition.
INTRODUCTION
Sports massage is ubiquitous in elite sport
and increasingly common at age- group and
amateur level, generating a multi- million
pound industry of professional therapists
and massage devices. The proposed bene-
fits of sports massage include improved
recovery, performance and injury preven-
tion1 2 but massage is both expensive and
time- consuming. Therefore, there is an
important need to delineate the evidence
base supporting such an intervention.
A previous meta- analysis of 22 randomised
studies found a small and inconsistent benefit
of massage on performance recovery after
exercise.1 This included studies using non-
manual techniques such as vibration or
water- jet massage that are not commonly
available, and outcomes such as flexibility
or delayed onset muscle soreness (DOMS)
were not examined. Another meta- analysis
examined the effect of several interventions
including massage on DOMS but included
only four studies of the effect of massage
at various time points, finding no signifi-
cant improvement of DOMS by massage.3
We therefore performed a comprehensive
systematic review and meta- analysis aiming
to examine the benefits of manual sports
massage on a range of outcomes including
performance, strength or recovery to better
inform the athlete and coach about whether
massage justifies inclusion in training or
competition.
METHODS
No universally accepted definition of sports
massage exists. For the purpose of this meta-
analysis we defined sports massage as manual
manipulation of muscles and soft tissue by
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
2DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
Figure 1 A owchart demonstrating the search strategy
used to identify eligible studies for the meta- analyses.
a qualified professional, with the purpose of improving
performance in or recovery from sport.
The Preferred Reporting Items for Systematic Reviews
and Meta- Analysis guidelines were followed in preparing,
conducting and reporting this systematic review.3
Eligibility criteria
We searched PubMed and Cochrane for publications
retrieved by searching in any field for: ‘sports massage’
(OR) ‘sports therapy’ (AND) ‘athlete’. We then refined
these to those including any of the following terms:
‘strength’, ‘sprint’, ‘flexibility’, ‘jump’, ‘endurance’,
‘range of motion’, ‘DOMS’, ‘delayed onset muscle sore-
ness’, ‘perceived recovery’, ‘psychological’, ‘fatigue’,
‘performance’, ‘recovery’. To be eligible, studies must
have evaluated the effect of manual massage on human
participants in a randomised study and include assessment
of sporting performance or recovery. Non- randomised
studies, or those using non- manual massage (eg, waterjet,
foam rollers, automated massage) were excluded.
Outcomes
We performed separate meta- analyses examining the
effect of massage on measures of sporting performance
(strength, jump, sprint, endurance and flexibility) and
recovery (fatigue and DOMS). Where studies analysed
the effect of massage at more than one time point, we
analysed the time point soonest after massage. This was
to avoid bias by including the same participants multiple
times in the same category (pseudoreplication) which
was a potential limitation of the previous largest meta-
analysis.1 Where studies included more than two groups
(for example comparing massage, control and a different
type of intervention) we analysed only the data for
massage and control groups.
Data collection and analysis
Data was collected and analysed by HD, SA and TC
using RevMan 5.3 software. Standardised mean differ-
ence (SMD) was calculated using RevMan 5.3 software
and used in the meta- analysis. Standardised mean differ-
ence (difference in mean outcome between groups/
SD of outcome) is a summary statistic to assess the same
outcome that has been measured in a variety of ways.
This allows expression of the size of the intervention
effect per study relative to the variability observed in that
study, and thus allows comparison of effect sizes between
studies using different outcome measures. Study hetero-
geneity was assessed by calculating the I2 value. I2 values
of 25%, 50% and 75% can be considered to reflect small,
moderate and large degrees of heterogeneity. A p value
<0.05 was considered statistically significant.
Patients and public were not involved in the design or
conduct of this study.
Description of included massage techniques
A range of massage techniques were applied in the
identified studies. Where available we indicate which tech-
niques were used in the study descriptions. ‘Effleurage’
consists of strokes delivered with the palm in the direc-
tion of lymphatic drainage and venous flow.2 4 ‘Petrissage’
involves lifting tissue away from underlying structures,
intending to improve circulation, loosen adhesions
between tissues and improve drainage of lymphatics.2 4
In ‘pincement’ the palms are placed vertically above the
part to be massaged, lightly picking up the tissue with
thumb and fingers.5 6 In ‘wringing' superficial tissues
are grasped in both hands and twisted in opposite direc-
tions.6 ‘Tapotement’ involves repeated light strikes to
the muscle.2 4 ‘Vibrations’ and ‘shaking’ are delivered by
trembling both hands in contact with the skin.6 ‘Friction
massage’ is a brisk, deep stroke transversely or parallel to
fibre direction.2 4 ‘Compressions’ have the same intent,
but use the palm to press down on the muscle.4
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
3
DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
Figure 2 Forest plot demonstrating the results of the meta-
analysis of the effects of manual massage (with 95% CIs) on
(A) strength performance (overall effect: p=0.17) and (B) jump
performance (overall effect: p=0.39). Std., standardised.
RESULTS
We identified 29 studies meeting our eligibility criteria;
12 randomised controlled trials (RCTs) and 17
randomised crossover studies (figure 1). A total of 1012
participants were included, substantially exceeding the
270 participants in the largest previous meta- analysis.1
Many studies assessed multiple outcomes. We analysed
these in separate meta- analysis of; strength, jump, sprint,
endurance, fatigue, flexibility and DOMS. Due to the
variability in study design and massage interventions,
we briefly describe each study to allow assessment of the
potential explanations for the effects observed. Studies
are described in order of negative to positive effects on
outcomes.
The effect of sports massage on strength performance
Twelve studies examined whether sports massage influ-
ences recovery of strength after exercise.
Arroyo- Morales et al randomised 60 participants to
20 min pre- event massage, consisting of effleurage, petris-
sage and tapotement, or placebo (detuned ultrasound).7
This found a significant decrease in peak isokinetic
torque of the quadriceps after massage but not placebo,
suggesting massage could negatively affect strength.
The same group conducted a further study evaluating
the effect of 40 min massage on strength after high inten-
sity exercise in 62 students.8 A placebo (sham ultrasound)
was used and participants fatigued by 3×30 s Wingate
tests. This study found massage reduced electromyog-
raphy (EMG) amplitude and vigour (EMG amplitude
was used as an indicator of muscle force) compared with
passive recovery after the Wingate tests.9
Jönhagen et al examined the effect of massage on
recovery of quadriceps strength and function after 300
maximal strength contractions in 16 participants.10
Twelve min of massage, including effleurage and petris-
sage, was administered immediately after exercise, then
daily for 3 days to one leg with the other used as control.
Massage had no significant effect on subsequent maximal
strength.
Hemmings et al tested the effect of massage on boxing
strength in eight amateur boxers using a counter-
balanced design with participants undergoing passive rest
or 20 min, including effleurage and petrissage between
repeated performances.11 This found no difference in
strength between groups.
Dawson et al examined the effect of repeated massage
on strength recovery after a half marathon in 10 recre-
ational runners.12 They received 30 min massage
including effleurage, petrissage and passive stretching, 1,
4, 8 and 11 days post- race on a single leg with the other
leg used as a control. Massage had no effect on rate of
return to baseline strength.
Hunter et al examined the effect of massage including
effleurage and petrissage on maximal voluntary contrac-
tions using electromyography in a crossover study with 10
participants. Massage induced no significant difference
in maximal voluntary contractions compared with passive
rest.13
Dawson et al also examined the effect of regular
massage over a longer period on novice recreational
runners.14 Participants took part in a 10- week running
preparation clinic and received massage (‘individualised
to each participant’) or no massage for 30 min weekly for
10 weeks. There were no significant differences between
groups in indices of strength.
Zainuddin et al examined the effects of 10 min massage
including effleurage, petrissage and friction after eccen-
tric elbow flexor exercise in a crossover study using 10
participants15 and found no significant improvement in
muscle strength after massage.
Hilbert et al investigated the effects of 20 min of
massage (including effleurage, petrissage and tapo-
tement) on muscle strength of 18 participants in a
crossover trial where the control condition was sham
massage. Hamstring peak torque, muscle soreness and
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
4DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
range of motion (ROM) were measured after eccentric
muscle contractions. This study found no improvement
in muscle strength with massage.16
In contrast to the above studies reporting negative
or neutral effects of massage on strength, others have
found massage may improve strength recovery. Sykaras
et al examined the effect of brief (2 min) massage (effleu-
rage, petrissage, friction, tapotement, pincement and
wringing) on 12 female Tae Kwon Do athletes’ knee
extensor peak torque after concentric/eccentric contrac-
tions.5 One leg was massaged, and the non- massaged leg
used as control. Massaged limbs performed significantly
better after exhaustive exercise.
Brooks et al studied the immediate effects of 5 min
manual forearm massage on power grip performance
after 3 min of maximal exercise.17 Fifty- two participants
were randomised to 5 min massage (including effleurage
and friction massage), passive rest or passive shoulder
movement. Massage was associated with a significantly
greater strength recovery.
Farr et al investigated the effects of massage including
effleurage and petrissage on muscle strength after 40 min
of downhill walking on a treadmill in eight male partic-
ipants. Isometric and isokinetic strength and single leg
vertical jump were measured. This study found that
30 min of massage after 40 min downhill walking was asso-
ciated with a significant benefit in strength recovery.18
Meta- analysis of these studies found that massage had
no overall effect on strength with low study heteroge-
neity (SMD 0.17, 95% CI −0.08 to 0.42; participants=346;
studies=12, I2=23% (figure 2A).
The effect of sports massage on jump performance
Five studies examined whether sports massage affects
jump performance. Jönhagen et al examined the effect
of massage on recovery of jumping performance after
300 maximal strength contractions in 16 participants.10
Twelve min massage was administered immediately after
exercise then daily for 3 days to a single leg with the other
used as control. Massage had no significant effect on one-
legged jump performance.
Delextrat et al recruited eight male and eight female
basketball players to a crossover trial testing the effect of
30 min of massage including effleurage and petrissage,
water immersion or passive rest on outcomes including
jump performance after a match.19 This found post-
match massage had no effect.
Mancinelli et al recruited 22 female volleyball and basket-
ball players. After baseline measurements of vertical jump
height, timed shuttle run, quadriceps femoris length and
pressure pain threshold were obtained, participants were
fatigued by pre- season training for 2 days before being
given 17 min effleurage, petrissage and vibration on
each quadriceps, or passive rest, and repeating the tests.
Massage did not significantly affect vertical jump height.20
Farr et al found no significant difference in standing
vertical jump performance after massage compared with
passive rest in the study described above.18
One study did find favourable effects of massage on
jump performance. Kargarfard et al randomised 30 male
body builders to 30 min massage (including effleurage,
petrissage and vibration) of the exercised muscle group
or passive rest after a fatigue- inducing protocol21 and
then assessed vertical jump performance of 30 male body
builders. The control group showed worsening vertical
jump performance at 48 and 72 hours, whereas the massage
group performance returned to baseline by 48 hours.
Meta- analysis of these studies found that massage had
no overall effect on jump performance with very low
heterogeneity (SMD 0.16, 95% CI −0.20 to 0.51; partici-
pants=132; studies=5; I2=5%) (figure 2B).
The effect of sports massage on sprint performance
Seven studies examined the effect of sports massage on
sprinting. Fletcher et al examined the effect of effleurage
and petrissage as ‘warm up’ before a 20 m sprint test.22
This found 9 min massage alone was associated with the
slowest sprint times, and there was no significant differ-
ence compared with control when massage was combined
with a ‘traditional warm up’ (4×30 s laps of a sports hall
plus 1×10 s passive stretching).
Goodwin et al studied the effect of massage on 30 m
sprint performance in a counterbalanced crossover
design.23 The conditions included 15 min of lower limb
massage including effleurage, petrissage and tapotement,
15 min of placebo ultrasound and passive rest. There
were no significant differences between any groups on
any measure of sprinting.
Delextrat et al also found no difference between passive
rest and massage in sprint times after competitive basket-
ball.19
Mancinelli et al found no significant difference on post
intervention sprint times after massage in basketball and
volleyball players.20
Robertson et al also investigated the effects of massage
or passive rest on cycling sprint performance recovery.24
Nine males were fatigued by 6×30 s high intensity efforts
with 30 s active recovery. Subjects received either 20 min
massage (including effleurage, petrissage, wringing,
picking up) or supine passive rest before a 30 s Wingate
test. Massage had no effect on maximum or mean power
in this test.
Ogai et al performed a crossover study25 of 11 females
who performed high intensity cycle sprints (5 s repeated
eight times with recovery intervals of 20 s). This was
repeated after 35 min of either passive rest or 10 min
massage (petrissage and compressions). In this study
sprint performance recovered significantly better in the
massage group.25
Meta- analysis found that massage had no overall effect
on sprint performance, with high study heterogeneity
(SMD −0.35, 95% CI −0.98 to 0.28; participants=257;
studies=7; I2=82%) (figure 3A).
The effect of sports massage on endurance performance
We identified three studies examining the effects of
massage on endurance.
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
5
DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
Figure 3 Forest plot demonstrating the results of the meta-
analysis of the effects of manual massage (with 95% CIs) on
(A) sprint performance (overall effect: p=0.27), (B) endurance
performance (overall effect=p=0.91) and (C) fatigue (overall
effect: p=0.22). Std., standardised.
Lane and Wenger examined the effects of active
recovery, massage, cold water immersion or passive rest
on repeated cycling performance 24 hours apart.26 The
cycling test lasted 18 min with high intensity intervals,
thus using both anaerobic and aerobic systems. Massage
included effleurage, petrissage and tapotement. Only
the passive rest group showed a significant decline in the
second performance, but there was no significant differ-
ence between groups.
Monedero and Donne studied the effect of massage on
endurance performance with pre- intervention and post-
intervention 5 km bike trials. Eighteen male cyclists were
randomised to either active recovery (gentle cycling),
massage (effleurage and tapotement), passive recovery
(lying down) or a combination of active recovery and
massage in a crossover study.27 Active recovery improved
post- intervention time trial times more than massage or
passive recovery.
Rinder and Sutherland recruited 13 males and 7 females
in a randomised crossover study who were fatigued using
an ergometer, ski squats and leg extensions followed by
6 min effleurage and petrissage or passive rest.28 Partic-
ipants then performed their maximum number of leg
extensions against half maximum load. The massage
group performed significantly more leg extensions post
intervention compared with the control group.
Meta- analysis of these studies found that massage had
no overall effect on endurance with very high study
heterogeneity (SMD 0.21, 95% CI −3.45 to 3.87; partici-
pants=96; studies=3; I2=97%) (figure 3B)
The effect of sports massage on muscle fatigue
Muscle fatigue is defined as loss of muscle power due to
a decline in force and velocity which is both measurable
and reversible by rest, which distinguishes muscle fatigue
from muscle weakness or damage.29 30 Perceived muscle
fatigue is a subjective assessment.
Hemmings et al (discussed above) examined the effect
of massage on performance on amateur boxers and
found that this significantly increased perceived fatigue
compared with control.11
Nunes et al conducted a double- blind RCT testing
whether massage reduces pain and perceived fatigue
in the quadriceps of 74 athletes after an Ironman
Triathlon.31 Massage techniques used were effleurage,
petrissage and tapotement. The massage group had
significantly lower subjective pain and fatigue ratings, but
there was no difference between the groups for pressure
pain threshold.
Conversely, Mancinelli et al found that although
massage had no effect on performance (described above)
it reduced perceived muscle fatigue20 as did Ogai et al.25
Hoffman et al examined the effect of massage and pneu-
matic compression for perceived fatigue and pain after
an ultramarathon.32 Seventy- two finishers of the 161 km
Western States Endurance Run were randomised into
three groups: control, massage (effleurage, compressions
and tapotement) and pneumatic compression. Those
receiving massage had significantly reduced perceived
fatigue ratings compared with control.
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
6DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
Figure 4 Forest plot demonstrating the results of the meta-
analysis of the effects of manual massage on (A) exibility
(overall effect: p<0.01) and (B) delayed onset muscle
soreness (DOMS) (overall effect: p<0.05).
Meta- analysis found no significant effect of massage on
fatigue with high study heterogeneity (SMD 0.47, 95% CI
−0.28 to 1.22; participants=171; studies=5; I2=86%)
(figure 3C).
The effect of sports massage on exibility
Flexibility is defined as the range of motion available to a
joint or joint series.33 Some sports benefit from extreme
ROM, such as ballet and gymnastics, while it is suggested
that for sports such as running, too much flexibility can
be detrimental and increase injury risk.33 34 Seven studies
examined the effect of massage on flexibility.
Barlow et al investigated the effect of a single hamstring
massage on a ‘sit and reach’ test. In a crossover design,
11 males received 15 min effleurage and petrissage or
control (supine rest) with a pre- intervention and post-
intervention sit and reach test. There was no significant
difference between the massage and control groups.35
Similarly, Zainuddin et al (discussed above) found no
significant effect of massage on range of motion of the
elbow joint.15
Huang et al studied the effect of massage on ROM of
the hamstring musculotendinous junction.36 Ten active
females were randomised to 30 s massage, 10 s friction
massage or passive rest. There were significant increases
in hip flexion ROM with 30 s of massage at the musculo-
tendinous junction of the distal portion of the hamstrings,
but no difference in passive leg tension or EMG findings.
Hopper et al evaluate the effects of two different massage
techniques on hamstring length in 39 female hockey
players.37 These were classic massage (effleurage, petris-
sage, shaking and picking up) and dynamic soft tissue
mobilisation (DSTM) (dynamic movement contraction
of target muscles with focussed deep strokes on areas of
tension). There were significant increases in hamstring
length in both massage groups compared with passive
rest, but no differences between the different massage
types. In a further study, Hopper et al also evaluated the
effect of DSTM and classic massage on 45 male hockey
players.38 Hamstring length was significantly greater after
DSTM compared with classic massage (including effleu-
rage, petrissage, shaking and picking up), and hamstring
lengths after either massage type were greater than after
passive rest. It is noteworthy that DSTM differs from
classic massage as it involves mobilisation of the joints
and is therefore also a form of flexibility intervention.38
McKechnie et al examined whether 3 min of petrissage
and tapotement would influence plantar flexor flexibility
and power of the lower leg in 19 participants.39 Ankle
joint flexibility was significantly increased with both
massage techniques, but there was no difference between
the two techniques.
Crosman et al studied the effects of hamstring massage
or passive rest on ROM in 34 females.40 Massage (including
effleurage, petrissage and friction massage) significantly
increased all ROM tests immediately after massage, but
this was not maintained, suggesting an immediate but
not long- term effect of massage on flexibility.
Meta- analysis of these studies found that massage
significantly increased flexibility scores by 7%, with very
high heterogeneity (p=0.01, SMD 1.07, 95% CI 0.21 to
1.93; participants=246; studies=7; I2=90%) (figure 4A).
The effect of sports massage on delayed onset muscle
soreness
DOMS is separate from though often co- exists with
perceived muscle fatigue. DOMS is muscular discomfort
following exercise experienced by athletes of all levels.41
The intensity of discomfort increases within 24 to 72 hours
post exercise, subsiding after 5 to 7 days.42 43 A hypothe-
sised benefit of sports massage is that it helps recovery
from both fatigue and DOMS.2 Ernst conducted a system-
atic review looking at the effect of post- exercise massage
treatment on the effect of DOMS.44 They included seven
studies and concluded that most of these were burdened
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
7
DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
with methodological flaws, and results were inconsistent.
However, most suggested that post- exercise massage
may help alleviate DOMS symptoms. In our review, we
included 10 studies examining the effect of massage on
DOMS. All studies relied on subjective rating scales to
assess DOMS.
Dawson et al studied the potential for repeated massage
to influence muscle recovery following an endurance
race in a field setting.12 Ten recreational runners who
completed a half marathon received 30 min massage days
1, 4, 8 and 11 post- race on one leg, while the other was
used as control. Muscle strength, pain and leg swelling
were assessed after each massage. Massage had no effect
on rate of return to baseline levels of DOMS and swelling.
Another study by the same group also found no differ-
ence in DOMS between runners who received regular
massage compared to those that did not.14 Zainuddin
et al similarly found massage did not alleviate DOMS or
muscle swelling.15
Hilbert et al investigated the physiological and psycho-
logical effects of 20 min of massage on DOMS after
eccentric contractions of the hamstring compared with
a sham massage.16 They found that massage did not
decrease DOMS compared with placebo.
Conversely, other studies have suggested that massage
may reduce DOMS. Kargarfard et al found massage
had no effect on performance (described in previous
section), but did significantly decrease perceived muscle
soreness 24, 48 and 72 hours post exercise.21
Hoffman et al (discussed above) examined the effect
of massage and pneumatic compression for DOMS after
an ultramarathon.32 They found that both massage and
pneumatic compression provided immediate pain relief
compared with control.
Similarly, Delextrat et al investigated the effect of 30 min
of massage, water immersion and passive rest on DOMS
after a competitive basketball match.19 Both massage and
cold- water immersion improved perception of recovery
and reduced DOMS, especially in females. Mancinelli
et al also found massage induced significant reduction
of muscle soreness in female collegiate basketball and
volleyball players, with 80% of those receiving massage
reporting decreased soreness.20
Farr et al (discussed above) found that massage signifi-
cantly aided alleviation of DOMS significantly.18 Nunes et
al (discussed above) also found that athletes who received
massage after the Ironman Triathlon experienced signifi-
cantly lower DOMS compared with control.31
Meta- analysis of these studies found massage was asso-
ciated with a statistically significant 13% improvement in
measures of DOMS after exercise, with high study hetero-
geneity (SMD 1.13, 95% CI 0.44 to 1.82; participants=311;
studies=10; I2=86%) (figure 4B).
DISCUSSION
Athletes and coaches often believe sports massage
improves performance.1 However, our meta- analysis find
no conclusive empirical evidence for benefits on the
outcomes of performance examined. Our meta- analysis
highlights the difficulty of defining such benefits; most
studies recruited small numbers of participants and the
effect size of massage (if such exists) may be too small to
be easily detected with low numbers, particularly if there
is variability in results. The array of different massage
protocols we describe makes defining optimum treat-
ment protocols highly complex. We found no evidence of
improvement in performance measures (strength, jump,
sprint or endurance), even though some studies might
have been expected to be affected by placebo effects.
There were also two studies that suggested massage
may have a detrimental effect on performance.7 8 Our
review therefore finds no evidence to justify inclusion of
massage with the expectation of direct improvement of
performance in strength, sprint or endurance.
We did find that massage induced a small but statisti-
cally significant improvement in flexibility, although the
large heterogeneity of these studies findings (I2=90%)
reflects the fact that this was influenced by a single outlier
study,30 with others showing a consistently smaller benefit.
Athletes that require flexibility may therefore benefit
from massage based on these findings, although further
research into specific sports is required to confirm this.
It is worth noting that the studies included compared
massage to no intervention, rather than other inter-
ventions such as passive stretching, which also have the
potential to improve flexibility.
We found that massage statistically significantly reduced
pain/DOMS by 13%, although again these studies
were highly heterogeneous (I2=86%) driven by a single
outlier17 so the true magnitude of any benefit remains
uncertain. These findings would imply that sports
more likely to induce DOMS have more to gain from
inclusion of massage, especially when repeated perfor-
mance before DOMS has recovered is required, such as
multi- day events. This benefit may be more important in
sports where analgesic use is restricted. However, given
the cost and time implications of massage, head- to- head
randomised control comparisons with other preventative
and analgesic strategies such as ice baths or compres-
sion would be required to understand the magnitude
of the benefit over other approaches. It is important to
recognise that studies on DOMS use subjective rating
assessments that are susceptible to placebo effects.
As well as direct effects on performance and recovery,
massage has been suggested to induce physiological
effects.45 46 Cambron et al47 studied the effect of different
forms of massage on blood pressure in non- athletes.
Effleurage and petrissage were associated with no signif-
icant change in blood pressure, while potentially painful
massage techniques, such as trigger- point therapy, were
associated with a significant rise in either diastolic or
systolic blood pressure. The applicability of these find-
ings to sports performance and recovery is unclear.
Zebrowska et al48 investigated the effectiveness of
different lymphatic drainage methods on the forearms
of mixed martial arts athletes after fatiguing exercise.
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
8DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
Drainage techniques included manual lymphatic drainage
(MLD), electro stimulation and deep oscillation (DO),
with a control group being exposed to non- therapeutic
light. This found a significant increase in blood velocity
associated with both MLD and DO although the effect on
performance and recovery was not examined.
Some studies have examined the effect of massage on
the autonomic nervous system, though none in a sporting
context. Fazeli et al,49 Guan et al50 and Lee et al51 have all
suggested that massage may reduce heart rate variability
and reduce cortisol levels, potentially demonstrating the
wider effects of massage.
The lactic acid theory suggests that lactic acid produced
during exercise contributes to pain, although this is
disputed,41 Zebrowska et al48 found that massage was asso-
ciated with a significant decrease in blood lactate with
MLD. Lactic acid decreased to baseline after 20 min of
MLD, whereas it remained elevated in the control group.
Further research is required to examine the clinical
significance of this effect.
Hemmings et al11 also measured the effects of massage on
blood lactate. As discussed above, massage was associated
with better perceived recovery compared with control.
However, the massage group had significantly higher
blood lactate levels at the time of the second exercise.
The authors suggested that increased perceived recovery
may have led to a greater effort and thus increased blood
lactate.11 45 Conversely, Robertson et al24 found no differ-
ence in blood lactate between massage and passive rest
interventions. Massage did not alter blood lactate levels
in Monedero and Donne,27 Hart et al52 or Dolgener and
Morien.53 In all these studies, active recovery was superior
to massage in decreasing blood lactate levels.
Our study has several limitations, particularly the wide
range of different study designs and protocols, and the
lack of statistical power for the metrics examined due
to the small size of the studies examined. However, our
work does represent the largest review of sports massage
so far conducted.
Our meta- analysis leaves many unanswered questions.
These include uncertainty over the optimum duration of
massage and the lack of studies testing the effect of regular
repeated massage, which might have more benefit. Given
the huge number of potential massage regimens and
timing, it is impossible to conclude that massage cannot
improve performance if the correct timing and indica-
tion could be defined. However, our findings should
make athletes and coaches cautious about claims that
massage will provide benefits for which there is little or
no evidence.
Twitter Timothy James Ainsley Chico @timchico
Contributors HD and TC conceived and conducted the study. All authors wrote the
manuscript.
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Datasets and results of analysis are available upon
request.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iD
Timothy James AinsleyChico http:// orcid. org/ 0000- 0002- 7458- 5481
REFERENCES
1 Poppendieck W, Wegmann M, Ferrauti A, etal. Massage and
performance recovery: a Meta- Analytical review. Sports Med
2016;46:183–204.
2 Moraska A. Sports massage. A comprehensive review. J Sports Med
Phys Fitness 2005;45:370–80.
3 Guo J, Li L, Gong Y, etal. Massage alleviates delayed onset muscle
soreness after strenuous exercise: a systematic review and meta-
analysis. Front Physiol 2017;8:747.
4 Paine T. The complete guide to sports massage, 2015.
5 Sykaras E, Mylonas A, Malliaropoulos N, etal. Manual massage
effect in knee extensors peak torque during short- term intense
continuous concentric–eccentric isokinetic exercise in female elite
athletes. Isokinet Exerc Sci 2003;11:153–7.
6 Goats GC, Mcsp P. Massage--the scientic basis of an ancient art:
Part 1. The techniques. Br J Sports Med 1994;28:149–52.
7 Arroyo- Morales M, Fernández- Lao C, Ariza- García A, etal.
Psychophysiological effects of preperformance massage before
isokinetic exercise. J Strength Cond Res 2011;25:481–8.
8 Arroyo- Morales M, Olea N, Martínez MM, etal. Psychophysiological
effects of massage- myofascial release after exercise: a randomized
sham- control study. J Altern Complement Med 2008;14:1223–9.
9 Kumar S, Narayan Y, Zedka M. An electromyographic study of
unresisted trunk rotation with normal velocity among healthy
subjects. Spine 1996;21:1500–12.
10 Jönhagen S, Ackermann P, Eriksson T, etal. Sports massage after
eccentric exercise. Am J Sports Med 2004;32:1499–503.
11 Hemmings B, Smith M, Graydon J, etal. Effects of massage on
physiological restoration, perceived recovery, and repeated sports
performance. Br J Sports Med 2000;34:109–14.
12 Dawson LG, Dawson KA, Tiidus PM. Evaluating the inuence
of massage on leg strength, swelling, and pain following a half-
marathon. J Sports Sci Med 2004;3:37–43.
13 Hunter AM, Watt JM, Watt V, etal. Effect of lower limb massage on
electromyography and force production of the knee extensors. Br J
Sports Med 2006;40:114–8.
14 Dawson KA, Dawson L, Thomas A, etal. Effectiveness of regular
proactive massage therapy for novice recreational runners. Phys
Ther Sport 2011;12:182–7.
15 Zainuddin Z, Newton M, Sacco P, etal. Effects of massage on
delayed- onset muscle soreness, swelling, and recovery of muscle
function. J Athl Train 2005;40:174.
16 Hilbert JE, Sforzo GA, Swensen T. The effects of massage on
delayed onset muscle soreness. Br J Sports Med 2003;37:72–5.
17 Brooks CP, Woodruff LD, Wright LL, etal. The immediate effects of
manual massage on power- grip performance after maximal exercise
in healthy adults. J Altern Complement Med 2005;11:1093–101.
18 Farr T, Nottle C, Nosaka K, etal. The effects of therapeutic massage
on delayed onset muscle soreness and muscle function following
downhill walking. J Sci Med Sport 2002;5:297–306.
19 Delextrat A, Calleja- González J, Hippocrate A, etal. Effects of sports
massage and intermittent cold- water immersion on recovery from
matches by basketball players. J Sports Sci 2013;31:1–9.
20 Mancinelli CA, Davis DS, Aboulhosn L, etal. The effects of massage
on delayed onset muscle soreness and physical performance in
female collegiate athletes. Phys Ther Sport 2006;7:5–13.
21 Kargarfard M, Lam ETC, Shariat A, etal. Efcacy of massage on
muscle soreness, perceived recovery, physiological restoration
and physical performance in male bodybuilders. J Sports Sci
2016;34:1–7.
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
9
DavisHL, etal. BMJ Open Sp Ex Med 2020;6:e000614. doi:10.1136/bmjsem-2019-000614
Open access
22 Fletcher IM. The effects of precompetition massage on the kinematic
parameters of 20- m sprint performance. J Strength Cond Res
2010;24:1179–83.
23 Goodwin JE, Glaister M, Howatson G, etal. Effect of pre-
performance lower- limb massage on thirty- meter sprint running. J
Strength Cond Res 2007;21:1028.
24 Robertson A, Watt JM, Galloway SDR. Effects of leg massage on
recovery from high intensity cycling exercise. Br J Sports Med
2004;38:173–6.
25 Ogai R, Yamane M, Matsumoto T, etal. Effects of petrissage
massage on fatigue and exercise performance following intensive
cycle pedalling. Br J Sports Med 2008;42:534–8.
26 Lane KN, Wenger HA. Effect of selected recovery conditions on
performance of repeated bouts of intermittent cycling separated by
24 hours. J Strength Cond Res 2004;18:855–60.
27 Monedero J, Donne B. Effect of recovery interventions on
lactate removal and subsequent performance. Int J Sports Med
2000;21:593–7.
28 Rinder AN, Sutherland CJ. An investigation of the effects of massage
on quadriceps performance after exercise fatigue. Complement Ther
Nurs Midwifery 1995;1:99–102.
29 Edwards RH. Biochemical bases of fatigue in exercise performance:
catastrophe theory of muscular fatigue. Biochem Exerc
1983;13:3–28.
30 Noakes TD, St Clair Gibson A, Lambert EV. From catastrophe to
complexity: a novel model of integrative central neural regulation
of effort and fatigue during exercise in humans: summary and
conclusions. Br J Sports Med 2005;39:120–4.
31 Nunes GS, Bender PU, de Menezes FS, etal. Massage therapy
decreases pain and perceived fatigue after long- distance Ironman
triathlon: a randomised trial. J Physiother 2016;62:83–7.
32 Hoffman MD, Badowski N, Chin J, etal. A randomized controlled
trial of massage and pneumatic compression for Ultramarathon
recovery. J Orthop Sports Phys Ther 2016;46:320–6.
33 Gleim GW, McHugh MP. Flexibility and its effects on sports injury
and performance. Sports Med 1997;24:289–99.
34 Gleim GW, Stachenfeld NS, Nicholas JA. The inuence of
exibility on the economy of walking and jogging. J Orthop Res
1990;8:814–23.
35 Barlow A, Clarke R, Johnson N, etal. Effect of massage of the
hamstring muscle group on performance of the sit and reach test. Br
J Sports Med 2004;38:349–51.
36 Huang SY, Di Santo M, Wadden KP, etal. Short- Duration massage at
the hamstrings musculotendinous junction induces greater range of
motion. J Strength Cond Res 2010;24:1917–24.
37 Hopper D, Conneely M, Chromiak F, etal. Evaluation of the effect of
two massage techniques on hamstring muscle length in competitive
female hockey players. Physical Therapy in Sport 2005;6:137–45.
38 Hopper D, Deacon S, Das S, etal. Dynamic soft tissue mobilisation
increases hamstring exibility in healthy male subjects. Br J Sports
Med 2005;39:594–8.
39 McKechnie GJB, Young WB, Behm DG. Acute effects of two
massage techniques on ankle joint exibility and power of the
plantar exors. J Sports Sci Med 2007;6:498–504.
40 Crosman LJ, Chateauvert SR, Weisberg J. The effects of massage
to the hamstring muscle group on range of motion. J Orthop Sports
Phys Ther 1984;6:168–72.
41 Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness
: treatment strategies and performance factors. Sports Med
2003;33:145–64.
42 Byrnes WC, Clarkson PM. Delayed onset muscle soreness and
training. Clin Sports Med 1986;5:605–14.
43 Armstrong RB. Mechanisms of exercise- induced delayed
onset muscular soreness: a brief review. Med Sci Sports Exerc
1984;16:529???538–38.
44 Ernst E. Does post- exercise massage treatment reduce delayed
onset muscle soreness? A systematic review. Br J Sports Med
1998;32:212–4.
45 Brummitt J. The role of massage in sports performance and
rehabilitation: current evidence and future direction. N Am J Sports
Phys Ther 2008;3:7–21.
46 Callaghan MJ. The role of massage in the management of the
athlete: a review. Br J Sports Med 1993;27:28–33.
47 Cambron JA, Dexheimer J, Coe P. Changes in blood pressure after
various forms of therapeutic massage: a preliminary study. J Altern
Complement Med 2006;12:65–70.
48 Zebrowska A, Trybulski R, Roczniok R, etal. Effect of physical
methods of lymphatic drainage on postexercise recovery of mixed
martial arts athletes. Clin J Sport Med 2019;29:49–56.
49 Fazeli MS, Pourrahmat M- M, Liu M, etal. The effect of head
massage on the regulation of the cardiac autonomic nervous
system: a pilot randomized crossover trial. J Altern Complement
Med 2016;22:75–80.
50 Guan L, Collet J- P, Yuskiv N, etal. The effect of massage therapy on
autonomic activity in critically ill children. Evid Based Complement
Alternat Med 2014;2014:1–8.
51 Lee Y- H, Park BNR, Kim SH. The effects of heat and massage
application on autonomic nervous system. Yonsei Med J
2011;52:982–9.
52 Hart JM, Swanik CB, Tierney RT. Effects of sport massage on limb
girth and discomfort associated with eccentric exercise. J Athl Train
2005;40:181–5.
53 Dolgener F, Morien A. The effect of massage on lactate
disappearance. J Strength Cond Res 1993;7:159–62.
copyright. on May 8, 2020 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000614 on 7 May 2020. Downloaded from
