Recovery Modalities for Athletes
Many athletes will face pain at some point in their life. This may be experienced in training or in their daily activities. Pain can inhibit athletes from reaching their full potential, enjoying their training, and alter their day-to-day activities. Pain is a highly motivating stimulus and athletes will often go to great extents to find a remedy for it. Additionally, poor recovery can lead to injury and pain, and should be a priority for athletes. But what are modalities (treatment methods) that are supported by research to get athletes back to doing what they love? This article will discuss the various modalities an athlete can utilize themselves or receive from a healthcare professional to mitigate their state of pain and increase their recovery.
What is pain and where does it come from? Pain is a protective mechanism that is relayed to our brain (i.e., central nervous system, CNS) in order for us to react and move to safety (shown in figure 1). For example, when you touch a hot stove, the receptors in your hand send signals up the arm, to the spinal cord, and into your brain to indicate the hand is being harmed. Next, your brain reads these signals, interprets what's happening, and sends a new signal back down through the spinal cord, through the nerves in your arm, and finally to your hand to initiate the reflex of pulling your hand away from danger (this signal travels at around 50 meters per second- fast!).
These receptors that sense pain are called “nociceptors” and send pain information through the spinothalamic or paleospinothalamic tract to relay information to the brain (Al-Chalabi et al., 2018). These same receptors are what sense stubbing your toe, touching a hot oven, pulling your hamstring, or the soreness you feel in your muscles a few days after a workout (delayed onset muscle soreness).
Many athletes are familiar with delayed onset muscle soreness. Delayed onset muscle soreness is theorized to be caused by contraction of the muscle which causes micro damage to the tissue (Sonkodi et al., 2020). This is the most accepted theory for the cause of delayed onset muscle soreness, but there are other theories postulated as well. For the purpose of this article, it is only important to know that delayed onset muscle soreness is caused by exercise and indicates the need for the athlete to rest and recover (Burnett et al., 2010).
Not all pain reaches the brain quickly. Pain that requires immediate reaction is fast and sent through nociceptive fibers that are thin and myelinated (myelination refers to a sheath-like covering that insulates the fibers and aids in the speed of a signal) located in the spinal cord. However, an aching pain that is dull uses bigger fibers that are non-myelinated. This allows the body to relay different types of pain.
Now that we know what pain is, the different ways pain can present, and its purpose, why should athletes care about it? Pain is common in athletes and often associated with injury (Hainline et al., 207). When an athlete is in pain they are unable to perform optimally, they may develop compensations that alter their movement patterns (subsequently leading to further injury), and their mental health will suffer. All of these factors contribute to an athlete ultimately underperforming. So, how do athletes respond to pain? The remainder of this article will discuss recovery modalities that research supports to decrease pain and increase recovery in athletes.
The focus of this article is specific for techniques or treatments that are supported by research. All athletes should include proper nutrition and sleep in their daily routine in order to recover to their full capacity. Outside factors like stress also contribute to overall health and an athlete's susceptibility to injury (Salim et al., 2015).
1). Dry needling is a modality that is minimally invasive and requires small needles inserted into areas where muscle or joint pain is present. Many athletes utilize dry needling through a chiropractor or physical therapist, and typically pair it with rehabilitation exercises to decrease recovery time (Korkmaz et al., 2022). Dry needling is similar to deep tissue massage but is administered in a fraction of the time. Likewise, dry needling has been found to mitigate symptoms of pain in people with results that lasted up to 3 months after 4 treatments (Martin-Corrales et al., 2020). Similarly, Koppenhave et al., (2016) found that patients who utilized dry needling made self-report of less pain that was statistically significant, had an increased range of motion in their shoulder (the area that the participants were receiving dry needling), and had an increase in pain threshold (the ability to withstand pain). Additionally, pain that is associated with a trigger point has been found to be significantly reduced with dry needling and, compared to other manual techniques, is a more efficient and a faster method (Dommerholt, 2011; Gerber et al, 2015).
A trigger point is an area of generalized local pain that can be acute (short-term) or chronic (long-term). This point of local pain can radiate to other surrounding regions. Evidence supports that trigger points develop from muscle overuse (Bron et al, 2012).
Additionally, Korkmaz and Ceylan (2022) found that when dry needling was paired with therapeutic exercises there was a reduction in the intensity of pain immediately, post-treatment and three months later. Lastly, dry needling has been found to decrease trigger point-associated pain regardless of the location and is more effective than stretching or percutaneous electrical nerve stimulation (Boyles et al., 2015).
Percutaneous electrical nerve stimulation (PENs) is similar to dry needling, but involves applying a small electric current into the needle. This modality is similar to a transcutaneous electrical nerve stimulation (TENs) which is commonly seen in an athletic recovery room (electrical stimulation is applied to the top of the skin through a pad that sticks to the skin).
2). Cupping consists of placement of either a cup that is heated or suctioned to the skin in order to over-stimulate pain fibers (causing the pain signal to subside), increase local blood flow (which improves recovery and healing), and stimulate collagen synthesis (a protein that aids in connective tissue healing/building, such as muscle). Likewise, cupping is supported by research to be successful in decreasing inflammation associated with training, as well as decreasing associated hypertonicity (muscle tension) (Lowe, 2017). Also, cupping has been shown to decrease chronic back pain (Castro Moura et al., 2018) and improve functional recovery by increasing soft tissue health (Chiu et al., 2020). Research shows cupping can improve range of motion as well (Murray & Clarkson, 2019).
3). A common modality that many athletes utilize on a daily basis is the foam roller. Researchers have found that rolling out muscles with foam rollers decreased stiffness in athletes and improved range of motion when used with dynamic stretching before and after a training session (Hendricks et al., 2020). Additionally, foam rolling has been found to increase recovery in exercise-induced muscle damage if the athlete foam rolls the sore muscle groups within 72 hours of the workout (Skinner et al., 2020). Similarly, foam rolling has been found to reduce muscle soreness in athletes that use it after training (D’Amico et al., 2020). Lastly, self-myofascial release, such as foam rolling, also improves recovery and can increase performance results when properly implemented (Richman et al, 2019). This can include foam rolling as well as other tools (such as rolling your foot out with a lacrosse ball).
There are varying results with other forms of self-myofascial release techniques, such as a massage gun. This is due to the fact that there are many types of massage guns available with different attachments and vibration frequencies. These variables can change the results produced and make the overall effects of a massage gun difficult to quantify without focusing on one brand. However, research supports that massage guns can be utilized before a workout to decrease perceived muscle soreness and increase range of motion in a muscle group before exercising (Martin, 2021).
4). Athletes can utilize high-velocity low-amplitude (HVLA) adjustments through a chiropractor to decrease chronic pain (pain lasting longer than 3 months) and acute pain (pain lasting less than 3 months). For example, Leemann et al., (2014) found that patients with acute and chronic lower back pain who utilized chiropractic care had significant improvement in their symptoms and a decrease in their reported pain levels. Similarly, a study found that CrossFit athletes with low back pain had a significant decrease in pain and increase in joint range of motion when receiving HVLA adjustments compared to athletes who did not (Moehlecke and Forgiarini, 2017). Also, research shows that HVLA adjustments paired with therapeutic exercises decrease pain from chronic ankle instability and improve range of motion, decrease pain, and increase stability (Shin et al., 2020). Overall, research supports that HVLA treatment can help stretch the surrounding soft tissue (muscles), release compression on nerve roots due to joint restriction, and prevent muscle atrophy (decrease in muscle size due to lack of use) (Chu et al., 2019). These results are ideal for athletes to perform optimally and pain free.
For a more in depth description of HVLA adjustments and what neurophysiological mechanisms are supported by research to cause change in the body, readers can view my previous article on the Morning Chalk Up community page, “A Case for Chiropractic Care: Do Athletes Need It?”
5). Near-infrared laser therapy is a modality that increases the mitochondria in muscle tissue (an organelle that is important for growth and repair of tissue). This modality can be performed by a physician, physical therapist, chiropractor, or other healthcare professionals who offer the service. Near-infrared laser therapy (also known as low-level laser therapy or cold laser therapy) is supported by research to improve muscle performance (Dos Reis et al., 2014). However, unlike the other modalities that are typically utilized after exercise, near-infrared laser therapy is beneficial before and after exercise. When athletes did a session of near-infrared laser therapy before their training, they produced results that supported that near-infrared laser therapy improved muscle performance and increased recovery (Abedi Yekta et al., 2021; Leal-Junior et al., 2015). Another study found that near-infrared laser therapy before a training session also increased the muscular strength gain of an athlete (Baroni et al., 2015). Also, research shows that near-infrared laser therapy after exercise increased muscle mass, reduced muscle soreness, and reduced muscle damage (Ferraresi et al., 2016). Essentially, near-infrared laser therapy has the same physiological mechanisms before and after exercise, but the goal of the therapy changes. For example, if the goal is to prevent injuries, use near-infrared laser therapy before exercise, and if the goal is improved healing of muscle tissues, use it after exercise.
For the readers interested, the mechanisms behind near-infrared laser therapy is due to the decrease of oxidative stress found in the body during and post exercise. This suggests that near-infrared laser therapy modulates the body’s redox system (a system that eliminates harmful free radicals from the blood) (De Marchi et al., 2012).
There is a difference between near-infrared laser therapy and just LED red light exposure (a modality growing in popularity to use in saunas or also administered in a tanning bed-like device). Near-infrared laser therapy uses a higher wavelength and is able to be focused on a certain area. This allows it to penetrate the skin and also accurately target an area. Red light therapy is a weaker wavelength without a focusing mechanism, making it less specific and less likely to penetrate the skin (this modality is helpful for healing wounds or reducing some scars versus muscle recovery) (Dungel et al., 2014).
So, which recovery modality should an athlete utilize? This may look different for each athlete based on available time, personal results, and finances. Figure 2 breaks down the discussed modalities.
This is not an exhaustive list, but represents popular modalities that are supported by research. Other modalities such as utilizing a sauna or cold therapy were investigated as well. For example, saunas showed a small or short-term effect on recovery in muscle (Jakeman et al., 2009; Mero et al., 2015), but did cause a significant increase in exercise tolerance (the maximum workload achieved during exercise)(Ohori et al., 2012). Cryotherapy showed a decrease in perceived muscle soreness due to less inflammation of the muscles, but further research is needed to investigate the full benefits and proper implementation (Kwiecien & McHugh, 2021) (Rose et al., 2017). In addition, other research found cold immersion therapy (submerging in water below 59 degrees Fahrenheit) showed similar results to cryotherapy. Cold immersion therapy reduced inflammation, swelling, and muscle soreness (Peake, 2019). However, the same study found that body composition influences the results of cold immersion therapy, and that protocols for usage changes based on the exercise performed (such as endurance exercises versus high-intensity training). Cold immersion therapy has consistent significant results for recovery, but the best mode of application for individual athletes still needs more research.
Overall, there are many modalities that an athlete can utilize to increase recovery and decrease pain. Depending on the time and resources available to each athlete can dictate which modality they use. The techniques discussed in this article are a good starting point for athletes looking to experiment with which modality unlocks their peak performance, in and outside of competition. Physical therapists, chiropractors, and other similar healthcare businesses often offer a variety of treatment methods. These facilities can be beneficial locations for guidance on recovery and an athlete to try different modalities to find what their peak recovery regimen entails. A pain free athlete is a better performing athlete (mentally and physically). Recovery modalities therefore increase athletic performance and should be utilized by all athletes.
For readers interested in the citations found in this article, email [email protected] for a reference page of all work cited.