Physical recovery modalities in competitive and elite endurance athletes: a systematic review and network meta-analysis finding limited evidence of benefit over passive recovery.

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 three outcomes. Certainty was very low for 31 of 47 comparisons and low for 15; the only moderate-certainty finding was that compression garments do not improve performance (SMD = 0.04, 95% CI -0.37 to 0.45). INTERPRETATION: No modality has been shown to outperform passive recovery on any outcome examined. For sport-specific performance this is an informative null: intervals for compression garments, active recovery and electrical stimulation exclude clinically important effects in both directions. Elsewhere the randomised base is too small and heterogeneous to support the modality-specific recommendations routinely made-the muscle-soreness network reverses when two of its five trials are removed-and a sham performing as well as the active modalities indicates that expectancy cannot be separated from physiological effect in this unblinded literature. Adequately powered, sham-controlled trials are required before these modalities can be recommended on efficacy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD420261368621.