08 June 2015

Massage and foam rolling in mountain ultramarathon running

For an ultramarathon runner it is obvious that training is damaging for muscles, soft tissues and bones and that it is necessary to balance the training with the right amount of recovery in order to improve the muscle strength and endurance. This balance quite often, at least for me, feels like walking on a knife-edge or a very thin ridge and by just losing the balance a little bit you could end up with a more serious injury like a stress fracture, a muscle strain or a more severe inflammation in a particular tendon or soft tissue. On the other hand, too little training for a period of time is also risking to fall of the knife edge or ridge as it not only mean less improvement, but also that the risk of injury might increase when ramping up and trying to catch up the lost training later on.

The past month I have been on the wrong side of the edge as I have had problems with my left leg. It started with the usual ankle and Achilles tendon pain I have had repeatedly the past few years – nothing worrisome and even though I hesitated a little bit I took the decision to run two back-to-back 20 mile trail runs on a weekend in the beginning of May – the last of those two runs with Hokas with a slightly more drop than usual. As I often have experienced my Achilles pain actually disappeared after these runs, the first time this happened I was quite surprised, but now I have learnt that this certainly could happen. The following week, when I focused more on hill repeats combined with strength training in the gym and some quite long road bike rides with my wife, I instead started to feel a numbing and pain in my left hamstrings. As always, it was initially quite difficult to distinguish “real” pain caused by some kind of stress or injury from muscle soreness, but after a while I realized that this probably was something more serious. In the middle of all of this I, quite embarrassingly, sustained a fall with my new road bike as I was not used to the pedals and cleats – it is indeed amazing how much you could damage yourself just by falling of a standing bike and I can still two weeks after the accident show some quite impressive abrasions on my left arm and knee. I might also have landed on my left buttock as I had a bruise there as well. The following days I referred the pain I felt, in particular after downhill running, in my left hamstrings and gluteus also to this fall. However, the past few days the pain in the hamstrings has finally subsided, but I am instead now feeling quite intense pain in my left buttock. Not the best thing to experience when sitting on numerous flights as I have been doing the past week. A few days ago I tried a foam roll for the first time in my life with the guidance of my PT and I could clearly feel that I have some kind of trigger point in my gluteus. It is likely only a slight muscle strain and it felt much better after releasing by the massage by the foam roll. But, I think it still too early to rule out the possibility of a more serious injury like a bone bruise or a pelvic stress fracture. As I do not have an MRI machine in my living room I will continue to walk on the knife edge until the pain has subsided or gotten even worse and when that happens I am quite sure I will instead have pain somewhere else, perhaps in my knee – it was a long time since I had that now when thinking about it.

This was a long introduction to the topic I was going to write about and that is massage and foam rolling for mountain ultramarathon running. I have actually never been had a massage and I have not until now used a foam roll, so clearly I am probably personally biased against the benefits of these activities as I otherwise would have used them. The reason I decided to write about them anyway was that I read a new article about massage during Tor des Géants (TDG) and those who has followed my blog knows that I have covered all scientific articles written on this race since I ran it myself in 2013. The article actually covers the year when I ran and I remember being offered to receive massage as part of the study at the life base in Donnas close to halfway around the 330 km tour of the Aosta valley. The article entitled “Effect of massage on DOMS in ultramarathon runners: A pilot study” is written by Lorenzo Visconti and colleagues and is in press in Journal of Bodywork & Movement Therapies. In the study, a total of 231 patients (210 males and 21 females; >45% of subjects were between 40-50 years old) were enrolled and treated with a 20-minute massage in the area that the subjects were complaining of symptoms. The area where the symptoms were most common was, not surprisingly, the lower extremities, with 60% of subjects complaining of leg problems, 23% complaining of thigh problems and 8% complaining of knee problems. The most common symptom of the delayed onset muscle soreness (DOMS) in >95% of participants was pain. To measure the effect of the massage the participants scored the degree of perceived pain intensity before and after treatment on a numeric pain rating scale (NPRS) from 10 to 0. Another scale, called the Patient Global Impression of Change scale (PGIC), which has been used in previous studies on massage effect, was also administered. Not surprisingly, immediately following the massage the level of pain measured by both scales were significantly reduced. This decrease in NPRS averaged 3.6 points (Standard deviation 2.1) and there were no cases that showed an increase in the NPRS scale after treatment. The PGIC values also improved after massage with values greater than the “much improved” in 80% of cases and was unchanged following treatment in only one case.

All of this is of course fine and might on a first quick (really quick) glance support the use of massage, but regretfully, this is not telling us anything about either the efficacy or the safety of massage during a mountain ultramarathon as obviously this study has major flaws. First of all, the selection of participants is greatly biased as it was done based on symptoms and willingness to try massage for those symptoms. I would personally have done anything to relieve my muscle soreness at the lifebase in Donnas, but as I did not believe massage would help me more than a short while I elected not to receive it. Quite interestingly, but in line with all other placebo effect research, the belief in massage has been shown to influence the perception of benefits also in running (Moraska “Massage efficacy beliefs for muscle recovery from a running race” Int J Therap Massage Bodywork 2013; 6: 3-8). Secondly, the study did not use a comparison with subjects not receiving massage. Thirdly, the effect measurement was done by the same persons performing the treatment. Fourth, the effect was measured immediately after treatment and there is no indication whether the effect was sustained even after the next climb up to Refugio Coda. Fifth, the massage was given after long downhill section of the race which had been relatively fast and easy to run with some road sections so the muscle soreness was probably at its peak at this point. Sixth, no information is available on the use of NSAIDs or other pain relieving medications. Seventh, no information is available on the previous use and experience of massage. Eight, no objective measurement of DOMS such as biochemical or other laboratory parameters were used.  I could probably find even more flaws with the study, but will stop here. I am not too concerned by the author’s statements that the massage had some positive immediate effects on DOMS, but I am more disturbed by the fact that they are claiming that the massage was completely safe without following the outcome of the runners for the rest of the race.

The study is interesting as a pilot experiment, however, and shows that it would be possible to do a proper prospective randomized controlled scientific study during this long race with a large number of participants. It is also an interesting study as it discusses some of the current knowledge in the area. However, also in this aspect the study has some major flaws as it leaves out plenty of the negative studies indicating lack of effect of massage for DOMS and performance in association with running (for instance Dolgener & Morien “The effect of massage on lactate disappearance” J Strength Cond Res. 1993; 7:159-162; Dawson et al. “Evaluating the influence of massage on leg strength, swelling, and pain following a half-marathon” J Sports Sci Med. 2004; 3: 37-43). A good, but somewhat old, review article is Brummit “The role of massage in sports performance and rehabilitation: Current evidence and future dirction” North Am J Sports Phys Therapy 2008; 3: 7-21. More recent review articles about massage for DOMS are Nelson “Delayed onset muscle soreness: is massage effective” J Bodyw Mov Ther 2013; 17: 475-482; Torres et al “Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: systematic review and meta-analysis” Phys Ther Sport 2012; 13: 101-114; Tejero-Fernandez et al “Immunological effects of massage after exercise; A systematic review” Phys Ther Sport 2015; 16: 187-192. I will not review all of this literature here, but just point out that 1) there exist to my knowledge no other studies of massage for ultramarathon running; and 2) that most of the studies of massage as a treatment for DOMS and for improvement of running performance has the same design flaws as the study by Visconti and colleagues and more and proper research is clearly needed.

In summary, the question whether massage and foam rolling is effective and safe in reducing muscle soreness and other issues in association with mountain ultramarathon running is still unanswered and open. However, personally, since I started to write this post it has passed some days and the pain in my left buttock is markedly improved so at least I will give foam rolling more of a try in the future now.

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