Massage therapy and exercise performance: A systematic review

Abstract

<h2>Abstract</h2> <p>Massage therapy is one of the oldest recovery interventions in athletic training, yet its scientific evaluation remains complicated by variability in technique, dosage, timing, and outcome measurement. This <a href="/terms/systematic-review/" class="term-link" data-slug="systematic-review" title="systematic review">systematic review</a> by Davis and Alabas (2020) synthesizes evidence from 29 studies examining the effects of massage on exercise performance recovery, delayed-onset muscle soreness (<a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a>), strength recovery, and physiological biomarkers of <a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="muscle damage">muscle damage</a>.</p> <p>The primary findings indicate that massage produces a moderate reduction in DOMS severity across multiple muscle groups and exercise modalities, with a pooled <a href="/terms/effect-size/" class="term-link" data-slug="effect-size" title="effect size">effect size</a> of approximately d = 0.5 [1]. Proposed mechanisms include enhanced blood flow and lymphatic drainage, reduced inflammatory mediator accumulation, and altered pain perception through mechanical stimulation of peripheral receptors. However, the evidence for massage-induced improvements in muscle strength recovery is considerably weaker and inconsistent, suggesting that DOMS relief may represent a perceptual effect that does not correspond with accelerated tissue regeneration [2, 3].</p> <p>Methodological quality across included studies was moderate, with notable limitations including heterogeneous massage protocols, inadequate blinding, and reliance on self-reported soreness as the primary outcome. Current evidence supports massage as a useful adjunct for DOMS management when applied 24-48 hours post-exercise, but practitioners should not expect substantial improvements in objective performance metrics. Massage is best integrated as one component of a comprehensive recovery program rather than as a standalone intervention.</p>

Introduction

<h2>Introduction</h2> <p>The use of massage for recovery from exercise has a history spanning centuries of athletic tradition, predating the emergence of modern sports science by millennia. Ancient Greek athletes employed regular massage in preparation for and recovery from competition; contemporary elite sport continues this tradition with dedicated massage therapists embedded within multidisciplinary support teams. This longevity of practice naturally confers a degree of face validity — <a href="/terms/intermittent-fasting/" class="term-link" data-slug="intermittent-fasting" title="if">if</a> massage were wholly without benefit, one might expect rational practitioners to have abandoned it — but practitioner experience and institutional traditions can perpetuate interventions of limited efficacy. A rigorous evidence-based evaluation is therefore warranted.</p> <p>The theoretical rationale for massage's recovery benefits is multifaceted. At the physiological level, massage is proposed to enhance local circulation, facilitating oxygen delivery to damaged tissue and clearance of inflammatory metabolites [4]. Mechanical deformation of soft tissue may directly reduce <a href="/terms/muscle-fiber/" class="term-link" data-slug="muscle-fiber" title="muscle fiber">muscle fiber</a> cross-linking and adhesion formation following eccentric-induced damage, potentially accelerating structural repair. Neurologically, the activation of mechanoreceptors and Ruffini endings may modulate autonomic nervous system tone and reduce pain signal transmission through gate control mechanisms [5].</p> <p>The <a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a> phenomenon — characterized by delayed peak soreness at 24-72 hours post-exercise, stiffness, and temporary loss of muscle function — is a natural target for massage intervention. DOMS impairs training quality, reduces exercise adherence, and, in competitive contexts, compromises performance in subsequent efforts. Despite widespread massage use for DOMS management, the quantitative evidence base has historically been insufficient to guide practice with confidence [6].</p> <p>This review by Davis and Alabas (2020) addresses this gap by systematically evaluating massage's efficacy across multiple recovery-relevant outcomes, applying modern meta-analytic methods to synthesize findings from a heterogeneous but informative body of literature.</p>

Evidence Review

<h2>Evidence Review</h2> <h3>Effects on Delayed-Onset Muscle Soreness</h3> <p>The most consistent finding across the massage literature is a reduction in perceived <a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a>. Meta-analytic synthesis across 29 studies yields a pooled <a href="/terms/effect-size/" class="term-link" data-slug="effect-size" title="effect size">effect size</a> of approximately d = 0.5, indicating a moderate beneficial effect [1]. This effect is observed across diverse exercise protocols (resistance training, distance running, downhill walking) and body regions (quadriceps, hamstrings, biceps brachii). The effect appears to be timing-dependent: massage administered within 24-48 hours post-exercise produces greater soreness relief than massage applied immediately post-exercise or more than 72 hours later [7].</p> <p>Studies utilizing pressure pain threshold (PPT) algometry as an objective measure of local tissue sensitivity confirm the self-report findings, with massage-treated sites exhibiting 15-25% higher PPT relative to control conditions at 48 hours post-exercise [8]. This provides a degree of objectivity that strengthens confidence in the DOMS findings beyond self-report alone.</p> <h3>Effects on Strength Recovery</h3> <p>The picture is considerably less optimistic for strength recovery. Of the studies included in this review that assessed maximal voluntary contraction (MVC) or peak torque as outcomes, the majority found no statistically significant difference between massage and control conditions at any post-exercise time point [2, 9]. Effect sizes for strength recovery were small and inconsistent in direction. This suggests that massage's pain-relieving effects do not correspond with accelerated restoration of force-generating capacity — a dissociation that challenges mechanistic explanations relying on enhanced tissue repair.</p> <h3>Biomarkers of <a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="Muscle Damage">Muscle Damage</a></h3> <p>Massage does not appear to significantly reduce circulating biomarkers of muscle damage, including <a href="/terms/creatine-monohydrate/" class="term-link" data-slug="creatine-monohydrate" title="creatine">creatine</a> kinase (CK) and myoglobin. Studies measuring these outcomes report minimal or no differences between massage and control conditions, despite concurrent reductions in perceived soreness [10]. This dissociation between subjective recovery and objective tissue damage markers is consistent with the interpretation that massage's primary mechanism is perceptual and neurological rather than directly regenerative.</p> <table> <thead> <tr> <th>Outcome</th> <th>Effect</th> <th>Consistency</th> </tr> </thead> <tbody> <tr> <td>DOMS (perceived)</td> <td>Moderate reduction (d ~ 0.5)</td> <td>High</td> </tr> <tr> <td>Pressure pain threshold</td> <td>Moderate improvement</td> <td>Moderate</td> </tr> <tr> <td>Maximal strength (MVC)</td> <td>Minimal effect</td> <td>Low</td> </tr> <tr> <td>Creatine kinase</td> <td>No meaningful reduction</td> <td>High</td> </tr> <tr> <td><a href="/terms/range-of-motion/" class="term-link" data-slug="range-of-motion" title="ROM">ROM</a></td> <td>Small improvement</td> <td>Moderate</td> </tr> </tbody> </table> <h3>Proposed Mechanisms</h3> <p>Three primary mechanisms have been proposed for massage's recovery effects. First, enhanced local circulation promotes metabolite clearance and oxygen delivery. Second, mechanical stimulation of the fascial system reduces interstitial pressure and edema. Third, neurological pathways — particularly gate control pain modulation and autonomic nervous system regulation — may be the predominant mechanism underlying pain relief [11]. The lack of effect on biomarkers and strength recovery is most consistent with the neurological explanation being primary.</p>

Discussion

<h2>Discussion</h2> <h3>The Perceptual-Objective Dissociation</h3> <p>Perhaps the most theoretically interesting finding of this review is the systematic dissociation between massage's effects on perceived soreness and its effects on objective outcomes — strength, power, and circulating biomarkers of <a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="muscle damage">muscle damage</a>. This pattern argues against a primarily physiological regenerative mechanism and suggests instead that massage works largely through modulation of pain perception and psychological state.</p> <p>From a practical perspective, this dissociation does not eliminate massage's value. Perceived soreness is itself a performance-relevant outcome: athletes experiencing severe <a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a> are more likely to modify or skip subsequent training sessions, compromising the adaptations they are seeking. A reduction in perceived soreness, regardless of its underlying mechanism, may translate into improved training adherence and reduced psychological burden — outcomes with genuine practical importance.</p> <p>However, the dissociation does caution against narratives that position massage as a means of "speeding healing" or "removing metabolic waste." The evidence does not support these mechanistic claims, and overstating massage's biological effects may lead athletes and practitioners to overweight it in their recovery hierarchies at the expense of more effective, evidence-supported interventions [12].</p> <h3><a href="/terms/dose-response-relationship/" class="term-link" data-slug="dose-response-relationship" title="Dose-Response">Dose-Response</a> Considerations</h3> <p>The literature suggests that massage duration matters, though optimal dosing remains uncertain. Studies employing 10-30 minute sessions report significant DOMS reduction, while sessions shorter than 10 minutes show inconsistent effects [7]. The relationship between pressure intensity and outcome is less clear — moderate pressure appears sufficient, with high-pressure massage in very sore tissue potentially counterproductive by exacerbating local inflammation.</p> <p>The type of massage technique also influences outcomes. Swedish massage and sports massage (incorporating effleurage, petrissage, and compression strokes) are the most studied modalities and show the most consistent effects. Deep tissue and trigger point techniques, while widely used, have limited controlled evidence supporting their specific efficacy over conventional techniques [13].</p> <h3>Methodological Limitations</h3> <p>The methodological landscape of massage research is challenging. The impossibility of blinding participants and therapists to treatment allocation creates substantial expectation bias risk. Studies that have attempted to control for expectation effects using "sham" massage or attention-matched control conditions typically report smaller effect sizes than uncontrolled studies, suggesting that some portion of the observed benefit reflects non-specific effects [14]. Additionally, commercial and professional interests in the massage industry may contribute to publication bias, with <a href="/terms/eccentric-contraction/" class="term-link" data-slug="eccentric-contraction" title="negative">negative</a> results less likely to be submitted or accepted for publication.</p>

Practical Recommendations

<h2>Practical Recommendations</h2> <p>Based on the available evidence, the following guidelines represent a reasonable synthesis for incorporating massage into recovery programs.</p> <h3>Optimal Timing</h3> <p>The evidence most strongly supports massage administered 24-48 hours post-exercise for <a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a> reduction. Immediate post-exercise massage may be less effective and, in cases of acute trauma or significant inflammatory response, potentially contraindicated. Practitioners should therefore integrate massage into the day-after-training schedule rather than immediately at the conclusion of a session [7].</p> <p>For competition contexts, massage during the warm-up period (30-60 minutes pre-performance) has been investigated with mixed results. Light effleurage techniques appear safe pre-competition, but deep pressure techniques may impair neuromuscular readiness and should be avoided within the hour before performance.</p> <h3>Duration and Technique</h3> <p>Sessions of 10-30 minutes targeting the primary muscle groups trained are appropriate for most recovery contexts. Longer sessions may confer marginal additional benefit but represent an opportunity cost relative to other recovery modalities or rest. Swedish and sports massage techniques are the most evidence-supported; practitioners should prioritize these over more exotic or expensive modalities absent compelling reason.</p> <h3>Integration with Comprehensive Recovery</h3> <p>Massage should be viewed as one component of a layered recovery strategy. Its primary documented benefit — moderate DOMS reduction — is valuable but limited in scope. For complete recovery optimization, massage should be combined with adequate sleep (the most powerful recovery intervention available), appropriate nutritional support (<a href="/terms/muscle-protein-synthesis/" class="term-link" data-slug="muscle-protein-synthesis" title="protein synthesis">protein synthesis</a> and glycogen replenishment), and hydration management [15].</p> <h3>Realistic Expectations</h3> <table> <thead> <tr> <th>Recovery Goal</th> <th>Evidence for Massage</th> <th>Alternative with Stronger Evidence</th> </tr> </thead> <tbody> <tr> <td>Reduce perceived soreness</td> <td>Moderate support</td> <td>Foam rolling, NSAIDs (short-term)</td> </tr> <tr> <td>Restore maximal strength</td> <td>Weak support</td> <td>Rest, sleep, protein nutrition</td> </tr> <tr> <td>Reduce CK/inflammation markers</td> <td>No support</td> <td>Rest, omega-3 supplementation</td> </tr> <tr> <td>Improve subsequent performance</td> <td>Weak indirect support</td> <td>Adequate sleep, carbohydrate nutrition</td> </tr> </tbody> </table> <p>Athletes and coaches should resist the temptation to schedule frequent massage appointments as a substitute for optimizing foundational recovery behaviors. Massage is a useful, pleasant addition to a recovery program — but its biological effects on tissue repair are more limited than is commonly assumed.</p>