August 2021

Lower Extremity Compression Garments Use by Athletes: Why, How Often, and Perceived Benefit

By Thierry P. C. Franke, Frank J. G. Backx, and Bionka M. A. Huisstede

The popularity of lower extremity compression garments (CGs) amongst athletes continues to increase. Initially CGs were mainly prescribed to patients with chronic venous disorder. Using graduated lower extremity CGs with a degrading pressure from distal to proximal parts of this extremity increases venous flow velocity, reduces venous wall distension, improves valvular function, and stimulates lymphatic outflow. Consequently, using graduated CGs diminishes venous hypertension and symptoms of the swollen extremity and improves venous hemodynamics of the affected extremity. Ultimately, the degrading pressure helps the venous blood to return to the heart. Since Berry and McMurray [1987] originally investigated the effects of CGs for athletes, research on their effects on sports performance and post-exercise recovery keeps emerging and the popularity of CGs keeps growing among athletes.

Multiple meta-analyses have investigated the effects of CGs on sports performance and post-exercise recovery. Engel et al [2016] found in their meta-analysis that using compression clothing, defined as knee-high socks, sleeves, or shorts, slightly improves running economy. …Use of compression sleeves or stockings slightly improves biomechanical variables, such as ground contact time, step frequency, step length and swing time, and the psychological variable perceived exertion. Whereas the meta-analysis by Da Silva et al [2018] found no effect of lower leg CGs on high-intensity exercise performance, defined as time difference in a maximum running test across specific distances (50–400 m, 800–3000 m, or > 5000 m), compared to no CGs or placebo garments. Regarding post-exercise recovery, two meta-analyses showed that using CGs decreases post-exercise leg soreness and delays the onset of muscle fatigue and exercise-induced muscle damage, respectively. These effects were attributed to an enhanced venous blood flow and lymphatic outflow.

Unfortunately, the aforementioned meta-analyses have included studies of different types of CGs with varying pressure gradients, and different populations, which could have introduced bias into their analyses. Thus, the literature remains inconclusive on the physiological effects of CGs. Nonetheless, in clinical practice sports medicine physicians, physiotherapists, and manufacturers suggest that CGs can be used to prevent sports injuries or to reduce symptoms of a current sports injury. However, in scientific literature no information can be found on the effect of CGs on the prevention of (recurrent) sports injuries. Thus, there is a gap between the clinical perspective on the application of CGs and the scientific literature as it is unclear why CGs are used to prevent or treat sports injuries. Moreover, little is reported about the type of athletes that use CGs, for which purposes they use CGs, and whether they perceive any effects from using CGs. This information can give direction to future (epidemiologic) research on this topic. Furthermore, it could inform clinicians and researchers on the expectations of athletes using CGs. Moreover, if athletes report using CGs for sports injury prevention or to reduce symptoms of a current sports injury, it would be of interest to know for which type of injury. Therefore, the aim of this study was to investigate which athletes use CGs, why athletes use CGs, when CGs are worn by athletes, and, in case of an injury or injury prevention, for which injuries CGs are used. Moreover, we investigated the perceived effects of the use of CGs by the athletes on primary and secondary injury prevention, symptoms from current sports injuries, post-exercise recovery, and sports performance. Additionally, we studied the association between the characteristics of the athletes, the use of CGs, and the odds of a current lower leg sports injury.

Figure 1

Method

This cross-sectional study involved 512 athletes who used lower extremity CGs. [They were recruited from a single manufacturer’s database {Herzog Medical B.V. Woudenberg, the Netherlands}.] Athletes completed a questionnaire on the type of CGs they used, and when and why they used them. They also reported their sports participation, past and current sports injuries, and the perceived benefits of using CGs. [Full methodology is available at the URL in the Editor’s Note.]

Results

Sample characteristics: which athletes use CGs

In total, 602 of 714 invited participants provided informed consent. Of these, 512 athletes completed the personal characteristics section of the questionnaire, met the inclusion criteria, and were included in this study. Fully completed questionnaires were returned by 490 (95.7%) of these athletes.

The 512 included athletes were categorized into endurance (88.1%, n=451 [median age, 41 yrs]) and non-endurance athletes (11.9%, n=61 [median age, 34 yrs]). Running was the most frequently reported primary sport (84.7%, n=382) for endurance athletes and obstacle course racing (24.6%, n=15) for non-endurance athletes. PRO sport compression socks were most frequently used by all athletes (59.2%, n=303), followed by PRO sports compression tubes (27.0%, n=138).

Why athletes use CGs

The most frequently reported primary reason of all athletes for using a CG was secondary sports injury prevention (48.6%, n=243) (Table 2). The second most common primary reason to use a CG was to reduce symptoms of a current sports injury (14.8%, n=74). The most reported secondary reason for using a CG was to facilitate post-exercise recovery (43.0%, n=215).

When athletes use CGs

The majority of athletes “always” (100–96% of the time) or “often” (95–75% of the time) used a CG during training (56.8%, n= 279) and competitions (72.9%, n=264) for their primary sport (Figure 1). However, athletes only “sometimes” (35–1% of the time) or “never” (0% of the time) used their CGs directly after or the day after training (64.1%, n=214) or competition participation (54.6%, n=155) for their primary sport.

Perceived effect of CGs reported by the athletes

Figure 2 shows the perceived benefit of the CGs reported by the athletes for the reasons for which they indicated to use their CGs, i.e. primary injury prevention, secondary injury prevention, post-exercise recovery, sports performance improvement, and symptoms of a current sports injury. Among the endurance and non-endurance athletes, 77.1% (n=236) and 88.2% (n=30) perceived that using a CG “partially” or “strongly” contributed to secondary injury prevention, respectively. Further, 84.9% (n=203) and 81.8% (n=27) perceived that they recovered faster after exercise when using CGs, respectively.

Figure 2

Sports injuries

Past sports injuries

Of the endurance and non-endurance athletes, 84.9% (n=372) and 84.2% (n=48) reported a sports injury in the past, respectively. Endurance athletes more often reported sports injuries with a gradual onset than non-endurance athletes (p=0.046). The most common injury locations reported by endurance athletes were the lower leg (64.8%, n=241) and knee (16.4%, n=61). For non-endurance athletes the most common injury locations were the lower leg (60.4%, n=29) and ankle (16.7%, n=8). Of all athletes who reported a sports injury in the past, 72.8% (n=306) used a CG for this injury.

Current sports injuries

In total, 20.2% (n=101) of all athletes reported having a current sports injury. The point prevalence of current sports injuries for endurance and non-endurance athletes was 20.3 and 19.7%, respectively. The sports injury incidence rate during the past three months was 2.0 (95% CI 0.7–3.3) and 0.9 (95% CI − 1.5- 3.2) per 1000 training hours for endurance and non-endurance athletes, respectively. Most current sports injuries had a gradual onset. Lower leg (62.9%, n=56), ankle (10.1%, n=9), and foot/toe (10.1%, n=9) injuries were the most common in endurance athletes, and lower leg 66.7% (n=8) and ankle 16.7% (n=2) injuries in non-endurance athletes. Of all athletes reporting a current sports injury, 71.3% (n=72) used a CG for this injury.

Factors associated with a current sports injury in runners using CGs

PRO sports compression socks or tubes were used by 326 runners. These runners were included in the logistic regression analyses in order to explore the associations between the prevalence of a current lower leg sports injury and the characteristics of these runners. Multivariate regression analysis showed that “always” using a CG during competition participation and training (OR 0.32, 95% CI 0.13–0.79), and an average running distance of ≥23 km (OR 0.72, 95% CI 0.53–0.99) were significantly associated with a lower prevalence of current lower leg sports injuries.

Discussion

The aim of this study was to describe which athletes use CGs, why athletes use CGs, and when athletes use CGs. …Almost half of the endurance athletes and more than half of the non-endurance athletes indicated that the most important primary reason to wear the CGs is secondary injury prevention. About 15% and 17% of the endurance and non-endurance athletes respectively reported that the second most reported primary reason was reducing symptoms of a current sport injury. These CGs were mainly used during training and competitions and to a lesser extent directly after or the day after a competition.

The best facilitator for athletes to start with (secondary) injury prevention was sustaining an injury. Athletes seem to get motivated to start using preventive measures after they have suffered from a sports injury. Our study showed that athletes see CGs as a preventive measure to reduce injuries. Hypothetically, wearing CGs might prevent (recurring) sports injuries. Wearing CGs reduces the oscillation of the calf muscles, specifically the medial-lateral movement and anterior-posterior movement of the calf muscles during running by ~ 13% and ~ 20% respectively. This reduced muscle oscillation also occurs when wearing compression shorts during a jumping movement. The main muscles of the calf, the gastrocnemius and soleus muscles, store energy during the beginning of the stance phase and later in the stance phase which contribute to forward propulsion and support during running. Consequently, this reduced oscillation of these muscles during repeated movement such as running might lead to less fatigue and could enable the plantar flexors to better attenuate the impact of the foot on the ground during early stance phase or provide greater forward propulsion later in the stance phase. The impact of the foot on the ground can be measured using the loading rate, which is a vertical ground reaction force parameter. A higher loading rate is associated with, for example, a higher risk of a tibial stress fracture. Therefore, wearing CGs could aid in attenuating the impact from foot to the ground at each heel strike by reducing the oscillation of the plantar flexor muscles during running in order to reduce the risk of a (recurring) sports injury. This hypothesized mechanism by which wearing CGs could attenuate the impact of the foot to the ground might explain why endurance athletes, especially runners, use CGs. However, due to the cross-sectional nature of our study we could not study causal associations. Therefore, it remains to be studied if using CGs reduces the risk of a (recurring) injury.

The most mentioned secondary reason for all athletes (47%, n=215) – after primary and secondary injury preventions as most reported primary reasons – to use CGs was stimulating post-exercise recovery. Multiple systematic reviews have investigated the effects of CGs on post-exercise recovery. The meta-analysis from Hill et al [2014], which included 12 studies, concluded that using CGs both during and after sports participation reduced the severity of delayed-onset muscle soreness. Additionally, in the meta-analysis from Engel et al it is reported that using compression clothing, defined in this study as knee-high socks, sleeves, shorts, or tights, decreased leg soreness and delayed the onset of muscle fatigue. Furthermore, levels of creatine kinase (CK), a marker of muscle damage, and lactate, a product of anaerobic glycolysis, were found to be lower in CG users than in CG non-users. Other studies reported similar findings. These findings might be explained by increased venous flow velocity and lymphatic outflow due to CG use. An increased venous flow velocity and lymphatic outflow might aid in the clearance of CK and lactate. Alternatively, the lower levels of CK and lactate could be a consequence of the pressure exerted by the CGs on the tissue reducing the diffusion of molecules from muscle cells into the intercellular plasma and thus into the venous blood flow. Moreover, irrespective of the precise mechanism, these physiological effects might explain the perceived benefits on pos-texercise recovery reported in our study. As stated above, within our study the athletes who used their CG for post-exercise recovery mostly used them during sports participation rather than directly after (Fig. 2). Considering the results from the above-mentioned studies it might be advisable for athletes who use CGs for sports recovery to use their CGs both during and after sports participation.

This study also reports on the perceived benefits of CGs. Of the athletes who aimed to use CGs for secondary injury prevention (80.5%), almost 90% reported that they perceived that using CGs strongly or partly contributed to this purpose. The athletes who aimed to use CGs for recovery, over 80% perceived faster recovery. Over 70% of those indicating that they use CGs for improvement of sports performance, actually perceived sports performance improvement.

Regarding the sports injuries reported within our study, the point-prevalence of current sports injuries was 20.3% and 19.7% among the endurance and non-endurance athletes, respectively. Most injuries had a gradual onset (65.3%, n=66) and were located in the lower leg (63.4%, n=64). Lower leg injuries had a point prevalence of 12.8%, which is similar to the prevalence reported in the scientific literature. …In our study CGs were mostly used for secondary injury prevention of lower leg injuries by injured athletes. Further, in the subgroup of 326 runners who used either the PRO sport compression sock or tube, using multivariate logistic regression analysis, we found that athletes who always wear their CGs during training and competition were significantly associated with a lower prevalence of a current lower leg running-related injuries. Future research is needed to study the causal relation between the use of CGs and lower leg injury incidence.

Limitations

Some limitations of this study should be addressed. Our study could potentially have overestimated the perceived benefits of CGs because a large proportion of the participants had used a CG for several years or because the CGs were from a single manufacturer. … The cross-sectional nature of the study means that it was only possible to investigate associations between the prevalence of lower leg sports injuries and the characteristics of the runners, CG usage, and average training kilometers per week. It was not possible to establish whether CG use is causally related to a lower prevalence of lower leg sports injuries.

Conclusion

  • CGs were mostly used by endurance athletes, of which more than 80% were runners.
  • Over 80% of all athletes aimed to prevent re-injury by using CGs; for almost 50% of these athletes, secondary sports injury prevention is the most important/primary reason for wearing CGs.
  • Other primary reasons indicated for the use of CGs were reducing symptoms of a current sports injury (14.5%), post-exercise recovery (14.3%), primary prevention (13.6%), and sports performance improvement (8.8%).
  • Almost 90% of those aimed to reduce recurrent injuries reported perceived effects of the use of CGs with regard to this goal/purpose.
  • Of those indicating that they use CGs for recovery after sports or improvement of sports performance, over 80% perceived faster recovery and over 70% perceived sports performance improvement, respectively.
  • Compression garments are used more during than after sports participation.
  • For runners, always using their compression sock or tube during training and competition and an average running distance of ≥23 km was significantly associated with a lower prevalence of lower extremity sports injuries.

This is an extended excerpt of an article with the same title that originally appeared in the journal BMC Sports Science, Medicine and Rehabilitation. 2021;13:31. Doi:10.1186/s13102-020-00230-8. Use is per the Creative Commons License CC BY 4.0. Some summarization and editing have occurred, figures have been renumbered, and references have been removed for brevity. Find the original article at https://bmcsportsscimedrehabil.biomedcentral.com/articles/10.1186/s13102-020-00230-8#citeas

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.