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.
Figure 1A flowchart demonstrating the search strategy used to identify eligible studies for the meta-analyses.
The effect of sports massage on strength performance
Twelve studies examined whether sports massage influences recovery of strength after exercise.
Arroyo-Morales et al randomised 60 participants to 20 min pre-event massage, consisting of effleurage, petrissage 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 intensity 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 electromyography (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 petrissage, 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 recreational 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 contractions 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 eccentric 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 tapotement) on muscle strength of 18 participants in a crossover trial where the control condition was sham massage. Hamstring peak torque, muscle soreness and 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 (effleurage, petrissage, friction, tapotement, pincement and wringing) on 12 female Tae Kwon Do athletes’ knee extensor peak torque after concentric/eccentric contractions.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 participants. 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 associated 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 heterogeneity (SMD 0.17, 95% CI −0.08 to 0.42; participants=346; studies=12, I2=23% (figure 2A).
Figure 2Forest 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.
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 basketball 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; participants=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 difference 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 basketball.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).
Figure 3Forest 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.
The effect of sports massage on endurance performance
We identified three studies examining the effects of massage on endurance.
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 difference 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 Participants 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; participants=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 pneumatic 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.
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 flexibility
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 musculotendinous 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, petrissage, 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 effleurage, 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).
Figure 4Forest plot demonstrating the results of the meta-analysis of the effects of manual massage on (A) flexibility (overall effect: p<0.01) and (B) delayed onset muscle soreness (DOMS) (overall effect: p<0.05).
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 hypothesised benefit of sports massage is that it helps recovery from both fatigue and DOMS.2 Ernst conducted a systematic 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 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 difference 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 psychological 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 significantly aided alleviation of DOMS significantly.18 Nunes et al (discussed above) also found that athletes who received massage after the Ironman Triathlon experienced significantly lower DOMS compared with control.31
Meta-analysis of these studies found massage was associated with a statistically significant 13% improvement in measures of DOMS after exercise, with high study heterogeneity (SMD 1.13, 95% CI 0.44 to 1.82; participants=311; studies=10; I2=86%) (figure 4B).
