*2.1.2 Massage in different sporting conditions (before, during, and after the sports event)*

The effects and goals of sports massage are divided according to the mechanical, physiological, nervous, reflexive, and psychological outcomes. The massage goals vary depending on the period when they are applied (before, during, or after the sports event). For example, the massage techniques applied before the sports event are mainly meant to prepare athletes by increasing performance and reducing the risk of sports injuries [3].

The positive effects of pre-game massage on athletic performance are based on the theoretical principles that massage yields the following benefits: (a) increased skin and muscle temperature; (b) increased metabolism; and (c) increased blood circulation, which improves oxygen transport to tissues and leads to a better balance in blood flow [4]. The preventive effects of sports massage in terms of injuries have been attributed to (a) improved passive and active elasticity, (b) increased muscle activation and performance, and (c) the psychological stimulation of the athlete [5]. However, some of these theoretical effects of pre-game massage have not been strongly supported by research as relevant research findings have been limited or yielded conflicting results.

The relationship between massage and an increase in surface temperature has been confirmed by previous research. Several studies have shown that massage via the rubbing of the skin and the subcutaneous tissues increases the local skin and intramuscular temperature and leads to hyperaemia [6–14]. It has been reported that even a 6-minute massage of the back significantly increased the area's temperature, which returned to pre-massage levels after 10 minutes [11].

Similar effects were confirmed in a study conducted by the Laboratory of Therapeutic Exercise and Sports Rehabilitation at the University of Patras, Greece, which found that sports massage in the gastrocnemius and quadriceps areas of young basketball players increased the skin temperature of said areas, with the temperature returning to normal after about one hour. This finding is of special clinical interest because increased tissue temperature reduces pain and increases the metabolic rate, which can improve the elasticity of collagen and result in better functionality as well as a possible prevention of musculoskeletal injuries. Finally, increased skin temperature leads to an increase in vascular permeability and better oxygenation [15].

However, although pre-game massage increases surface and intramuscular temperature, such changes may not directly affect local blood and lymph circulation as studies have shown that massage can lead to significant [5, 14, 16, 17], moderate, or even zero increase in blood circulation [18–22].

The conflicting research findings on the effects of massage on blood circulation can be attributed to several factors. First, the positive effects of massage on skin temperature seem to subside relatively quickly [10]. Second, the increase in intramuscular temperature does not seem to exceed 2.5 points in muscle depth, meaning that it does not significantly affect the main vessels of the muscle [11].

In addition, researchers have mainly investigated deep effleurages rather than other manipulations. Moreover, the main techniques used for evaluating blood circulation (venous occlusion plethysmography, the Xenon-washout technique, Doppler ultrasound) have run into significant validity problems. Another researched factor that clearly influences the effect of massage on blood circulation is the intensity of the pressure applied to the tissues. Evidence supports the academic and sensible theory that classic relaxation massage leads to lower blood pressure, while intense athletic massage leads to increased blood pressure [17].

The relationship between massage and improved elasticity has been confirmed by several studies [23–29] that have shown positive muscle-elasticity adjustments after the application of massage. Studies have found that pre-game massage is associated with a relatively short-term (up to 24 hours) improvement in the elasticity of hamstrings [23–25, 29, 30] and plantar flexors of the ankle joint [31] in athletes and non-athletes. Improved muscle elasticity is causally related to the massage techniques applied. Intense and dynamic movements, such as intense deep-friction [30] in combination with eccentric exercise [32, 33], contributes more effectively to a short-term increase in tissue elasticity. This improvement is attributed to the reduction of myotendinous stiffness and increased stretch tolerance [30].

In contrast to elasticity improvements, scholars have not conclusively determined the effects of massage on the production of tension (strength), with some studies reporting a relative increase of post-exercise muscle strength after massage as assessed by various laboratory and functional tests with college students [27] and volleyball athletes [34], and other studies showing a significant reduction in post-exercise strength produced immediately after the application of massage [23–25, 29, 30, 35].

Finally, pre-game massage seems to significantly improve athlete psychology, with massage being associated with a reduction in pre-game stress in athletes, which contributes to better performance [36] by reducing stress hormones (cortisol and norepinephrine) and increasing serotonin levels [36, 37].

#### *2.1.3 Pre-game massage*

The manipulations performed to prepare an athlete for a sporting event mainly involve effleurages (superficial and deep), petrissage (flat petrissage), stimulating rolling, and kneading. These manipulations are mainly applied to the athlete's muscular groups that will be overloaded and will receive more use depending on the movement patterns of each sport. Considering that almost all sports, under normal conditions, are related to and depend on the movement of the lower extremities, the pre-game massage is logically focused mainly on the preparation of the muscles of the lower extremities. In addition, pre-game massage should also prepare (a) the body's central point (trunk), which provides the biomechanical basis for the initiation and proper execution of athletic movements, and (b) the upper limbs in cases of sports whose movement patterns include extensive use of the upper limbs (handball, volleyball, basketball, etc.).

Raising the temperature of the soft tissues before exercise is imperative to prepare the muscles for the intense loads that will follow in the game [38]. Massage can improve the temperature of the superficial muscle tissues, thus better preparing the athlete to enter the sports field [39].

The Laboratory of Therapeutic Exercise and Sports Rehabilitation at the Department of Physiotherapy at the University of Patras, Greece, has obtained positive results when it comes to studying massage and pre-game preparations: Charalampopoulou et al. concluded that soft tissue techniques, including IASTM and massage, can raise the skin temperature in basketball players for 15 minutes after the massage application [15].

#### *2.1.4 Massage during the game*

In sports that involve a break or breaks between competitive efforts, massage can improve athletic performance by allowing the athletes to temporarily cool-down (physically and psychologically) and preparing (activating) them for the continuation of the competition [4]. The main problems that an athlete faces during intense

#### *Soft-Tissue Techniques in Sports Injuries Prevention and Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.96480*

and competitive exercise are physical as well as psychological. Physical adaptations include muscle pain, increased muscle tone (spasm) of particularly stressed limbs, and edemas-hematomas. Psychological adaptations depend on various factors (the competition's importance, half-time result, etc.) and may include either personal competitive stress for better individual performance or psychological pressure for better team performance and goal achievement (in the case of team sports).

Depending on the manipulations chosen and the way they are performed (slowly superficially, superficially, in-depth), sports massage during half-time can lead to initial cool-down and reduction of the painful muscle tone and muscle excitability and to neuromuscular readiness as the game recommences [40, 41]. Moreover, massage can also reduce competitive stress and calm the athlete [42–44].

The research efforts that have examined this parameter have, despite their disadvantages (no control group, small sample of examinees), highlighted a significant correlation between massage and the improvement of the athlete's psychological parameters [42–44]. In terms of psychological rehabilitation, massage has been associated with a significant improvement in an athlete's sense of physical recovery, an outcome that is very important for the continuation of competitive efforts [45–47].

#### *2.1.5 Massage techniques after the game*

The main problems that an athlete faces after the competition (depending on its intensity and duration) are (a) fatigue from the accumulation of metabolism and waste products, (b) the accumulation of edemas and possible hematomas resulting from the excessive use of and strain on the athlete's anatomical structures, and (c) the immediate and delayed onset muscle soreness and the significantly increased muscle tone (spasm) of the limbs. Due to these effects and adjustments, athletes' physical properties (muscular strength, endurance, elasticity, proprioception) decrease significantly, and recovery should indirectly aim to correct these issues.

Post-competition massage as a means of passive rehabilitation can significantly contribute to an athlete's recovery and reduce the aforementioned physiological adaptations, but to a lesser extent than active recovery (e.g., aerobic running) [48–50].

Initially, by increasing blood flow to the muscles [51–53], massage can speed up the removal of useless metabolism products after exercise and improve the transport of oxygen, protein, and other nutrients necessary for muscle recovery and restart, leading to homeostasis [51, 54–56]. In addition, massage can significantly reduce feelings of fatigue and muscle pain as massage can help reduce the concentration of carcinogens (lactic acid) after exercise by improving blood flow to the muscles and subsequently increasing oxidation [57–59]. However, it should be noted that although massage leads to a significant reduction in the levels of lactic acid in the blood after intense exercise (compared to passive rest), active recovery (aerobic running) [49, 50, 59] the combination of massage and active rehabilitation [60] clearly exhibits better metabolic effects. In addition, massage has been shown to contribute positively to athletes' (soccer players') recovery in terms of heart rate and blood pressure compared to passive rest, with soccer players exhibiting better heart-rate recovery after lower extremity massage compared to active and passive recovery modes [50].

In summary, increased lymphatic circulation and venous resuscitation resulting from the application of sports massage after intense exercise can reduce the swelling and hematomas created during the exercise. The aforementioned adaptations, together with the local increase in temperature, can contribute to reduced muscle tone and improved relaxation [61–63]. The reduction of the concentration of hematomas and edemas caused by intense and prolonged exercise leads to a reduction of pain through a corresponding reduction of hydrostatic pressure and irritation of the sensory receptors of pain [64]. These outcomes of post-game massage are well supported by several studies that have shown that massage can reduce the intensity of DOMS in athletes and thus contribute to faster and better recovery [63, 65].

Finally, massage has been found to lead to faster recovery of strength levels compared to passive movement or rest as 5 minutes of massage (rolling, flat kneading) resulted in better grip strength of healthy people (non-athletes) after maximum exercise [16, 66]. Two additional studies examining the recovery of isokinetic power in the quadriceps muscle described improvement and increase of isokinetic power after 6-minute and 10-minute massages [67, 68].

#### *2.1.6 Therapeutic sports massage*

The soft tissue techniques of sports massage used to treat sports injuries are mainly applied in the physiotherapy laboratory during the rehabilitation phase. These techniques are performed by the sports physiotherapists as well as the athletes themselves in the case of self-massage with special equipment, such as a foam roller.

An important difference between therapeutic sports massage and the classic therapeutic massage has to do with the fact that in the case of therapeutic sports massage, the massage is not applied exclusively to the massaged area in a relaxed position but can also be combined with active (concentric-eccentric) or passive movement of the involved muscle group [33].

#### *2.1.7 Goals of therapeutic sports massage*

The main goals of therapeutic sports massage are the mobilisation of hematomas-edemas in the subacute phase of sports injuries, the alignment of injured tissue fibres, the release of adhesions, and the recovery of the elasticity of various tissues [69]. The main techniques used to achieve these objectives are the linear techniques of classic massage, except in the case of regaining elasticity and adhesion release, which requires special massage techniques, such as stripping massage, transverse friction massage, and aggressive forms of myofascial massage-mobilisation, such as foam roller, IASTM, and cupping therapy.

#### *2.1.8 Mobilisation – reduction of edemas/hematomas*

Massage can play an important role in repairing sports injuries by helping to reduce the concentration of both primary edemas caused by the injury and secondary edemas caused by increased hydrostatic pressure in the injured area [3, 70]. In addition, in cases where the injury has damaged several blood vessels and has led to a significant accumulation of hematomas, massage can mobilise this accumulation of blood and drastically reduce the healing time of an injury through the application of mechanical pressure to the vessels and tissues in general and the subsequent increase in local blood and lymphatic circulation [4, 26, 71–73].

By applying mechanical pressure to the tissues and vessels, massage mobilises the content of the valvular veins and the lymphatic channels in a more central direction (towards the heart), thus facilitating the entry of the interstitial fluid into the vessels [74, 75]. At the same time, vascular congestion can be reduced via the reduction of the median pressure, thus improving the diffusion-supply of the tissues [13].

#### *Soft-Tissue Techniques in Sports Injuries Prevention and Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.96480*

Improved drainage of fluids in the injured area also restores the normal osmotic pressure of the interstitial fluid, a process that is equally important to the vascular adjustments seen after the application of massage. These theoretical effects of massage on venous return and lymphatic circulation are supported by findings from studies of animals, which have shown that massage significantly increased lymphatic circulation compared to diathermy and active and passive exercise when applied to dogs [76, 77] and pigs [78].
