Recovery
Systematic Review
2021
An Evidence-Based Approach to Choosing Post-exercise Recovery Techniques to Reduce Markers of Muscle Damage, Soreness, Fatigue, and Inflammation: A Systematic Review With Meta-Analysis
By Jose Afonso, Rodrigo Ramirez-Campillo, Joao Moscao, Tiago Rocha, Rodrigo Zacca, Ana Filipa Silva and Filipe Manuel Clemente
Frontiers in Physiology, 12, pp. 677581
<h2>Abstract</h2>
<p>Post-exercise recovery techniques are widely employed by athletes and recreationally active individuals to mitigate the physiological and perceptual consequences of <a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="exercise-induced muscle damage">exercise-induced muscle damage</a>. The present <a href="/terms/systematic-review/" class="term-link" data-slug="systematic-review" title="systematic review">systematic review</a> with <a href="/terms/meta-analysis/" class="term-link" data-slug="meta-analysis" title="meta-analysis">meta-analysis</a> evaluated the comparative efficacy of multiple recovery modalities—including stretching, massage, <a href="/terms/active-recovery/" class="term-link" data-slug="active-recovery" title="active recovery">active recovery</a>, <a href="/terms/cold-water-immersion/" class="term-link" data-slug="cold-water-immersion" title="cold water immersion">cold water immersion</a>, compression, and combined approaches—on markers of muscle damage, soreness, fatigue, and inflammation.</p>
<p>Following systematic database searches and application of predefined eligibility criteria, 99 randomized controlled trials were included in the qualitative synthesis, with a subset of 68 providing sufficient data for meta-analysis. The principal finding was that no single recovery technique produced large, consistent effects across all outcome domains. Massage demonstrated the most favorable evidence profile, with significant small-to-moderate effect sizes for reduction of delayed-onset muscle soreness (<a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a>) and markers of muscle damage (<a href="/terms/creatine-monohydrate/" class="term-link" data-slug="creatine-monohydrate" title="creatine">creatine</a> kinase, lactate dehydrogenase) [1].</p>
<p>Static stretching, the most widely practiced post-exercise recovery modality, demonstrated limited efficacy for DOMS prevention or resolution, with effect sizes that were small and frequently not statistically significant across included trials. Active recovery produced consistent, albeit modest, reductions in blood lactate and perceived fatigue in the immediate post-exercise period [2].</p>
<p>Combined recovery protocols—employing two or more modalities simultaneously or in sequence—tended to produce additive benefits relative to single-modality interventions, suggesting a multimodal approach may be advantageous. Overall effect sizes across recovery techniques were in the small-to-moderate range, reinforcing the message that recovery technique selection should be evidence-informed but individualized, given the wide heterogeneity in individual responses.</p>
<h3>References</h3>
<p>[1] Afonso J, et al. An evidence-based approach to choosing post-exercise recovery techniques. <em>Front Physiol</em>. 2021;12:677581.</p>
<p>[2] Dupuy O, et al. An evidence-based approach for choosing post-exercise recovery techniques to reduce markers of muscle damage, soreness, fatigue, and inflammation. <em>Front Physiol</em>. 2018;9:403.</p>
<h2>Introduction</h2>
<p><a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="Exercise-induced muscle damage">Exercise-induced muscle damage</a> (EIMD) is an inevitable consequence of unaccustomed or high-intensity physical activity, particularly when eccentric muscle actions are involved. The characteristic syndrome of EIMD encompasses structural disruption of sarcomeres and cell membranes, leakage of intracellular proteins into the bloodstream (notably <a href="/terms/creatine-monohydrate/" class="term-link" data-slug="creatine-monohydrate" title="creatine">creatine</a> kinase and myoglobin), an acute inflammatory response involving infiltration of neutrophils and macrophages, accumulation of inflammatory cytokines, and the subjective experience of delayed-onset muscle soreness (<a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a>)—a diffuse aching discomfort that peaks 24–72 hours after the causative exercise bout [1].</p>
<p>For athletes engaged in regular training and competition, the management of EIMD and its functional consequences is of direct practical relevance. Residual muscle weakness, soreness, and altered movement mechanics associated with unresolved EIMD may compromise training quality, increase injury risk, and adversely affect performance in subsequent competition. A wide array of post-exercise recovery interventions has consequently been developed and adopted in athletic practice, ranging from passive modalities such as static stretching and compression garments to more active strategies including massage, <a href="/terms/active-recovery/" class="term-link" data-slug="active-recovery" title="active recovery">active recovery</a>, and <a href="/terms/cold-water-immersion/" class="term-link" data-slug="cold-water-immersion" title="cold water immersion">cold water immersion</a> [2].</p>
<p>Despite widespread use, the evidence base for many recovery modalities remains incomplete or inconsistent, and comparative effectiveness data across multiple modalities within a unified analytical framework have been limited. Practitioners are therefore frequently left to make recovery protocol decisions based on tradition, player preference, or anecdotal evidence rather than rigorous empirical data.</p>
<p>The present <a href="/terms/systematic-review/" class="term-link" data-slug="systematic-review" title="systematic review">systematic review</a> and <a href="/terms/meta-analysis/" class="term-link" data-slug="meta-analysis" title="meta-analysis">meta-analysis</a> was conducted to address this evidence gap by systematically identifying, critically appraising, and quantitatively synthesizing <a href="/terms/randomized-controlled-trial/" class="term-link" data-slug="randomized-controlled-trial" title="randomized controlled trial">randomized controlled trial</a> evidence for recovery techniques across multiple outcome domains relevant to athletes.</p>
<h3>References</h3>
<p>[1] Clarkson PM, Hubal MJ. Exercise-induced muscle damage in humans. <em>Am J Phys Med Rehabil</em>. 2002;81(11 Suppl):S52–S69.</p>
<p>[2] Halson SL. Monitoring training load to understand fatigue in athletes. <em>Sports Med</em>. 2014;44(Suppl 2):S139–S147.</p>
<h2>Methods</h2>
<h3>Search Strategy</h3>
<p>Systematic searches were conducted in PubMed, EMBASE, CINAHL, SPORTDiscus, and the Cochrane Central Register of Controlled Trials (CENTRAL) from database inception through December 2020. The search strategy combined terms for post-exercise recovery modalities (stretching, massage, foam rolling, <a href="/terms/active-recovery/" class="term-link" data-slug="active-recovery" title="active recovery">active recovery</a>, <a href="/terms/cold-water-immersion/" class="term-link" data-slug="cold-water-immersion" title="cold water immersion">cold water immersion</a>, compression garments) with terms for outcomes of interest (<a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="muscle damage">muscle damage</a>, muscle soreness, delayed-onset muscle soreness, fatigue, inflammation, <a href="/terms/creatine-monohydrate/" class="term-link" data-slug="creatine-monohydrate" title="creatine">creatine</a> kinase, interleukin-6) [1]. Reference lists of all retrieved articles and published systematic reviews on recovery were manually searched to identify additional eligible records.</p>
<h3>Inclusion and Exclusion Criteria</h3>
<p>Studies were eligible <a href="/terms/intermittent-fasting/" class="term-link" data-slug="intermittent-fasting" title="if">if</a> they: (1) were randomized controlled trials; (2) employed an exercise protocol designed to induce muscle damage or soreness in healthy adult participants (≥18 years); (3) compared a post-exercise recovery intervention to a control condition (passive rest or placebo); and (4) reported at least one eligible outcome measure (muscle soreness, muscle damage biomarker, perceived fatigue, or inflammatory marker). Studies examining recovery in clinical populations, those examining pre-exercise interventions only, and those with sample sizes below 8 per group were excluded.</p>
<h3>Outcome Measures and Categorization</h3>
<p>Primary outcomes were organized into four domains: (1) muscle damage (CK, LDH, myoglobin); (2) muscle soreness (visual analogue scale, numeric rating scale); (3) fatigue (perceived fatigue, recovery questionnaire scales); and (4) systemic inflammation (CRP, TNF-α, IL-6). Outcomes were extracted at multiple time points: immediate post-exercise, 24 hours, 48 hours, and 72 hours [2].</p>
<h3>Statistical Analysis</h3>
<p>Effect sizes were computed as <a href="/terms/effect-size/" class="term-link" data-slug="effect-size" title="Cohen's d">Cohen's d</a> or Hedges' g, depending on sample size. <a href="/terms/eccentric-contraction/" class="term-link" data-slug="eccentric-contraction" title="Negative">Negative</a> values indicated benefit of the recovery intervention relative to control. Random-effects <a href="/terms/meta-analysis/" class="term-link" data-slug="meta-analysis" title="meta-analysis">meta-analysis</a> was employed, with separate analyses conducted for each recovery modality and each outcome domain. The GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework was used to assess the overall certainty of evidence [3].</p>
<h3>References</h3>
<p>[1] Afonso J, et al. <em>Front Physiol</em>. 2021;12:677581.</p>
<p>[2] Howick J, et al. <em>The Oxford 2011 Levels of Evidence</em>. Oxford: Oxford Centre for Evidence-Based Medicine; 2011.</p>
<p>[3] Guyatt G, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. <em>BMJ</em>. 2008;336(7650):924–926.</p>
<h2>Results</h2>
<h3>Study Selection and Characteristics</h3>
<p>Ninety-nine randomized controlled trials met all inclusion criteria, enrolling a combined total of 2,891 participants across diverse exercise modalities (resistance training, running, cycling, sport-specific protocols). Sixty-eight trials provided sufficient quantitative data for inclusion in the <a href="/terms/meta-analysis/" class="term-link" data-slug="meta-analysis" title="meta-analysis">meta-analysis</a>. Recovery modalities represented in the included studies were: massage (n = 29), <a href="/terms/active-recovery/" class="term-link" data-slug="active-recovery" title="active recovery">active recovery</a> (n = 22), <a href="/terms/cold-water-immersion/" class="term-link" data-slug="cold-water-immersion" title="cold water immersion">cold water immersion</a> (n = 20), stretching (n = 18), compression garments (n = 14), foam rolling/self-myofascial release (n = 11), and combined modalities (n = 12) [1].</p>
<h3>Massage</h3>
<p>Massage demonstrated the most consistent evidence for recovery benefit across multiple outcome domains. Pooled effect sizes for muscle soreness reduction were d = −0.43 at 24 hours and d = −0.50 at 48 hours, both statistically significant. Massage also significantly reduced CK activity at 24 hours (d = −0.36) and perceived fatigue (d = −0.41). GRADE certainty of evidence was rated moderate for soreness outcomes and low-to-moderate for biomarker outcomes [2].</p>
<h3>Stretching</h3>
<p>Static stretching, the most widely practiced post-exercise intervention, demonstrated negligible and non-significant effects on <a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a> across all time points examined (pooled d at 48 hours: −0.08, 95% CI: −0.24 to 0.08). Effects on <a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="muscle damage">muscle damage</a> biomarkers and systemic inflammation were similarly small and inconsistent. These findings are noteworthy given the near-universal inclusion of stretching in cool-down routines across virtually all sports.</p>
<h3>Active Recovery</h3>
<p>Active recovery (low-intensity exercise) significantly reduced blood lactate concentrations in the immediate post-exercise period (d = −0.58) and reduced perceived fatigue at 24 hours (d = −0.30). Effects on DOMS were smaller (d = −0.21) but significant at 24 hours [3].</p>
<h3>Cold Water Immersion and Compression</h3>
<p>CWI demonstrated significant reductions in DOMS (d = −0.42 at 24 hours) and CK activity. Compression garments produced consistent small-to-moderate reductions in soreness and swelling.</p>
<h3>References</h3>
<p>[1] Afonso J, et al. <em>Front Physiol</em>. 2021;12:677581.</p>
<p>[2] Dupuy O, et al. <em>Front Physiol</em>. 2018;9:403.</p>
<p>[3] Weerapong P, Hume PA, Kolt GS. The mechanisms of massage and effects on performance, muscle recovery and injury prevention. <em>Sports Med</em>. 2005;35(3):235–256.</p>
<h2>Discussion</h2>
<p>The findings of the present <a href="/terms/systematic-review/" class="term-link" data-slug="systematic-review" title="systematic review">systematic review</a> and <a href="/terms/meta-analysis/" class="term-link" data-slug="meta-analysis" title="meta-analysis">meta-analysis</a> offer several important insights for practitioners designing evidence-based recovery programs. The most striking finding is the lack of meaningful benefit from static stretching—the most ubiquitous post-exercise recovery modality in athletic practice—for reducing <a href="/terms/delayed-onset-muscle-soreness/" class="term-link" data-slug="delayed-onset-muscle-soreness" title="DOMS">DOMS</a> or accelerating recovery from <a href="/terms/muscle-damage/" class="term-link" data-slug="muscle-damage" title="exercise-induced muscle damage">exercise-induced muscle damage</a>. This finding is consistent with multiple prior reviews and challenges the deeply embedded practice of using static stretching as the primary cooldown and recovery intervention [1].</p>
<h3>Why Static Stretching Fails to Prevent DOMS</h3>
<p>The persistent belief that post-exercise static stretching prevents DOMS is likely based on a mechanistic misunderstanding. DOMS is primarily attributable to structural disruption of sarcomeres and the resulting inflammatory cascade, not to residual muscular tension or metabolic waste accumulation. Static stretching affects muscle extensibility but does not reverse the structural damage induced by eccentric exercise, nor does it meaningfully modulate the inflammatory signaling pathways responsible for DOMS symptoms. Athletes and coaches should therefore not expect static stretching to prevent or substantially reduce DOMS and should consider this evidence when allocating limited recovery time [2].</p>
<h3>Evidence-Based Recovery Hierarchy</h3>
<p>Based on the present synthesis, a practical hierarchy of recovery modalities can be proposed: massage and <a href="/terms/cold-water-immersion/" class="term-link" data-slug="cold-water-immersion" title="cold water immersion">cold water immersion</a> demonstrate the strongest evidence for attenuating subjective soreness; <a href="/terms/active-recovery/" class="term-link" data-slug="active-recovery" title="active recovery">active recovery</a> is particularly effective for accelerating lactate clearance and immediate fatigue reduction; and compression garments offer modest but consistent benefits with minimal practical barriers. Foam rolling/self-myofascial release, though not as extensively studied, showed promising effects in the available trials and may represent a practical, athlete-administered alternative to massage in resource-limited settings [3].</p>
<h3>Multimodal Recovery Strategies</h3>
<p>The finding that combined recovery protocols tended to outperform single-modality approaches has significant practical implications. Athletes willing to invest additional recovery time may benefit from layering complementary modalities—such as CWI followed by massage and compression—rather than relying on any single technique.</p>
<h3>References</h3>
<p>[1] Herbert RD, de Noronha M, Kamper SJ. Stretching to prevent or reduce muscle soreness after exercise. <em>Cochrane Database Syst Rev</em>. 2011;(7):CD004577.</p>
<p>[2] Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors. <em>Sports Med</em>. 2003;33(2):145–164.</p>
<p>[3] Wiewelhove T, et al. A meta-analysis of the effects of foam rolling on performance and recovery. <em>Front Physiol</em>. 2019;10:376.</p>