Physical recovery modalities in competitive and elite endurance athletes: a systematic review and network meta-analysis finding limited evidence of benefit over passive recovery
Abstract
Background: Physical recovery modalities are routine in elite sport, yet whether any outperforms passive recovery, and whether the evidence supports modality-specific recommendations, remains unestablished.
Methods: We searched PubMed, Embase, CENTRAL and Web of Science from inception to 1 April 2026 for randomised controlled trials of physical recovery modalities in competitive endurance athletes. Random-effects network meta-analyses were fitted for eight outcomes with passive recovery as reference, reporting standardised mean differences (SMDs) with 95% confidence intervals and P-scores. Certainty of evidence was rated with CINeMA against a minimal important SMD of 0.5, and risk of bias with RoB 2 (PROSPERO: CRD420261368621).
Findings: Sixteen RCTs (273 participants) met inclusion; fourteen contributed to at least one network. Of 47 contrasts against passive recovery, three excluded the null, but none robustly: two rested on single-trial nodes and all three on networks pooling incommensurable measures. No modality outperformed passive recovery for delayed-onset muscle soreness (5 trials; I-squared 90.2%), creatine kinase (4 trials), or sport-specific performance (11 trials; I-squared 0%). The evidence base was thinner than the trial count implies: 35 of 55 nodes (64%) rested on a single trial, and restricting to confirmed elite participants left four of eight outcomes with no estimable network. A thermoneutral-immersion sham ranked at or above every active modality on all…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 273 participants or records.
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