Approximately 1 percent of the US population will run a marathon in their lifetime. After such a physically demanding event, most athletes seek recovery through ice baths, compression clothing, or massage therapy. Postexercise massage is thought to improve muscle strength, decrease delayed onset muscle soreness, reduce swelling, and possibly increase blood circulation.
Pneumatic compression is a form of treatment frequently used in hospitals to improve circulation in patients’ legs when they are bedridden. This form of care is increasing in popularity for postexercise symptoms of swelling and pain, and is thought to have similar results to postexercise massage.
In a recent clinical trial, researchers compared massage therapy with pneumatic compression for ultramarathon recovery.1 The Western States Endurance Run ultramarathon is 161 kilometers, covers mountain trails, and takes a minimum of 14 hours to complete. Muscle soreness and loss of functional capacity typically lasts for several days after such a difficult race, lending to an ideal setting for comparison of recovery treatments.
In this study, subjects were recruited through email 46 days prior to the race. All race entrants were invited to participate. If willing to join, subjects were asked to perform two 400-meter runs as fast as possible during the month before the ultramarathon and to electronically submit the timed results to the investigators. At race registration, interested subjects then provided full consent and pre-race data.
Immediately after the race, subjects were escorted to a temperature-controlled tent for data collection and treatment interventions. Subjects were asked to submit further information during the seven days following the race.
Subjects who completed the race and were still willing to participate were randomized to one of three groups: therapeutic massage (n=25), pneumatic compression (n=24), or control intervention (n=23). All interventions started within 45 minutes postrace and lasted for 20 minutes. Subjects randomized to the control group rested in the supine position on a cot for 20 minutes without any other intervention.
The massage protocol included effleurage, compression, and tapotement to the lower extremities in the prone and supine positions. Massage was provided by three highly experienced sports massage therapists who used prerecorded audio files defining the timing and location of treatment and who practiced the treatment pre-race to ensure consistency of treatment.
Subjects receiving intermittent pneumatic compression were fitted with full-length pneumatic boots on both lower extremities while in the supine position. The pump used the protocol recommended by the manufacturer, which included compression to 80 mmHg of four circumferential chambers. Beginning with the most distal chamber and moving cephalad, each chamber was sequentially inflated for 8–10 seconds, then partially deflated for 15 seconds. The inflation and deflation of each chamber in a cephalad direction continued for the full 20 minutes.
Pain (soreness) and fatigue were measured pre-race, immediately postrace, upon standing after receiving the assigned intervention, and for seven days postrace approximately 30 minutes after waking. Two final 400-meter runs at maximal speed were also performed on days three and five postrace, with the results being electronically submitted to investigators.
The results immediately after the treatment demonstrated that subjects in the massage group had significantly lower muscle pain compared to the control group, and both massage and pneumatic compression resulted in lower muscular fatigue compared to the control group.  However, there were no differences in pain, fatigue, or 400-meter run times between the three groups during the seven days postrace.

Study Limitations
There were several limitations to this study. First, the self-report measures of pain and fatigue are subjective and could be affected by many factors. Also, the 400-meter times were all self-reported, possibly leading to bias or error. Third, approximately 40 percent of the subjects took NSAIDs during the race. Even though the percentage of use was similar between groups, this may have led to an overall change in the results. Finally, this study only assessed one 20-minute session. A different treatment duration, session number, or treatment style may have led to improved outcomes.
Many other studies have measured massage for recovery after various forms of athletic performance. A recent systematic review provided an overview of previous clinical trials on this topic.2 To be included in this review article, clinical trials had to include: massage as an intervention for recovery purposes, pre/post measures of physical performance, and a control group with passive recovery. The investigators found 1,123 potential articles, of which only 22 met all inclusion criteria. Of the 22 studies discovered, five used automated massage through a vibration, water jet, or compression device, and 17 used classic manual massage that typically included effleurage and petrissage (occasionally with vibration, friction, or tapotement) performed by a trained physiotherapist.

Findings
The results of the manual massage within the 17 studies demonstrated greater benefit with shorter massage durations, such as 5–6 or 8–12 minutes, as opposed to treatment sessions of more than 15 minutes that showed unclear or negligible effects.
With regard to the type of athletic performance leading to fatigue, massage therapy was most beneficial for mixed exercise and demonstrated only negligible effects for strength or endurance exercise. Interestingly, massage was more beneficial for untrained subjects compared to trained athletes.  
This review is limited to the information found in the included studies and, therefore, cannot provide a full perspective on the literature in this field. Other limitations of this study include the mix of athletic events, massage durations, and massage types. Combining the results of these varied articles should be interpreted with caution. Finally, the results of many outcome measures were combined, including upper- and lower-body strength measures, jump ability, and endurance timing. Pooling of these measures may not be appropriate.

Conclusion
Overall, it appears that 5–12 minutes of postevent massage may be beneficial for exercise recovery, especially in individuals who have limited athletic training and who are participating in mixed forms of exercise. However, more research is needed.   

Notes
1. M. D. Hoffman et al., “A Randomized Controlled Trial of Massage and Pneumatic Compression for Ultramarathon Recovery,” The Journal of Orthopaedic and Sports Physical Therapy 46, no. 5  (May 2016): 320–6. doi: 10.2519/jospt.2016.6455.
2. W. Poppendieck et al., “Massage and Performance Recovery: A Meta-Analytical Review,” Sports Medicine 46, no. 2 (February 2016): 183–204. doi: 10.1007/s40279-015-0420-x.

Jerrilyn Cambron, DC, PhD, MPH, LMT, is an educator at the National University of Health Sciences and president of the Massage Therapy Foundation. Contact her at jcambron@nuhs.edu.