Post-Competition Recovery Strategies in Elite Male Soccer Players. Effects on Performance: A Systematic Review and Meta-Analysis

RESEARCH ARTICLE Post-competition recovery strategies in elite male soccer players. Effects on performance: A systematic review and meta-analysis Albert Altarriba-BartesID 1,2☯ , Javier PeñaID 1,2☯ *, Jordi Vicens-BordasID 2,3,4☯ , Raimon Milà-Villaroel 5‡ , Julio Calleja-Gonza ´lezID 6‡ 1Sport Performance Analysis Research Group (SPARG), University of Vic-Central University of Catalonia, Vic, Barcelona, Spain, 2UVic-UCC Sport and Physical Activity Studies Centre (CEEAF), University of VicCentral University of Catalonia, Vic, Barcelona, Spain, 3Department of Medical Sciences, Research Group of Clinical Anatomy, Embryology and Neuroscience (NEOMA), School of Health and Sport Sciences (EUSES), University of Girona, Girona, Spain, 4School of Health and Sport Sciences (EUSES), Universitat de Girona, Salt, Spain, 5Global Research on Wellbeing (GRoW), Blanquerna School of Health SciencesRamon Llull University, Barcelona, Spain, 6Department of Physical Education and Sports, Faculty of Education and Sport, University of the Basque Country, UPV/EHU, Vitoria-Gasteiz, Spain ☯These authors contributed equally to this work. ‡ These authors also contributed equally to this work. *[email protected]at Abstract Aims The main aim of the present review was to update the available evidence on the value interest of post-competition recovery strategies in male professional or semi-professional soccer players to determine its effect on post-game performance outcomes, physiological markers, and wellness indicators. Methods A structured search was carried out following the PRISMA guidelines using six online databases: Pubmed, Scopus, SPORTDiscus, Web of Science, CINAHL and Cochrane Central Register of Controlled Trials. The risk of bias was completed following the Cochrane Collaboration Guidelines. Meta-analyses of randomized controlled trials were conducted to determine the between and within-group effects of different recovery strategies on performance, physiological markers and wellness data. Final meta-analyses were performed using the random-effects model and pooled standardized mean differences (SMD). Results Five randomized controlled trials that used Compression Garments (n = 3), Cold Water Immersion (n = 1), and acute Sleep Hygiene Strategy (n = 1) were included. Greater CMJ values at 48h for the intervention group (SMD = 0.70; 95% CI 0.14 to 1.25; p = 0.001; I 2 = 10.4%) were found. For the 20-m sprint and MVC, the results showed no difference either at 24h or 48h. For physiological markers (CK and CRP) and wellness data (DOMS), small to large SMD were present in favor of the intervention group both at 24h (-0.12 to -1.86) and PLOS ONE PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 1 / 20 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Altarriba-Bartes A, Peña J, Vicens-Bordas J, Milà-Villaroel R, Calleja-Gonza ´lez J (2020) Postcompetition recovery strategies in elite male soccer players. Effects on performance: A systematic review and meta-analysis. PLoS ONE 15(10): e0240135. https://doi.org/10.1371/journal. pone.0240135 Editor: Moacir Marocolo, Universidade Federal de Juiz de Fora, BRAZIL Received: May 20, 2020 Accepted: September 19, 2020 Published: October 2, 2020 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0240135 Copyright: ©2020 Altarriba-Bartes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the manuscript and its Supporting Information files. 48h (-0.21 to -0.85). No heterogeneity was present, except for MVC at 24h (I 2 = 90.4%; p = 0.0012) and CALF DOMS at 48h (I 2 = 93.7%; p = 0.013). Conclusion The use of recovery strategies offers significant positive effects only in jumping performance (CMJ), with no effects on the 20-m sprint or MVC. Also, the use of recovery strategies offers greater positive effects on muscle damage (physiological markers and wellness data), highlighting the importance of post-match recovery strategies in soccer. Introduction The interaction between training load, fatigue, adaptation, and recovery is an element of extreme complexity comprising factors of a very different nature [1,2]. According to the literature, maximizing the performance of an athlete is not only a matter of training, but it is also affected by a wide array of intrinsic and extrinsic elements [2,3]. Current evidence highlights that enough and optimal recovery is necessary to prevent health problems and to achieve peak performance and the choice of recovery strategies by coaches and athletes may be crucial [4, 5]. Proper recovery strategies can lead athletes to better performances, helping them to feel more rested and healthy [6]. However, high-performance athletes face a wide array of daily training stimuli that may not allow complete recoveries [7], emphasizing the need for optimal recovery strategies based on individual fatigue thresholds [4,8]. Recovering as quickly as possible, restoring pre-performance levels is considered a crucial element of success in almost every athletic discipline [9]. For this reason, coaches and athletes are always in a continuous search for the most effective strategies to speed up post-exercise recovery [2,9–11]. However, precisely defining the concept of “recovery from exercise” is a challenging mission due to the number of variables affecting an optimal recovery [12]. This pioneering idea has inspired a multi-factorial approach to the “physiology of recovery,” evidencing the need for more conclusive research [13]. Placing the focus on fatigue in elite competitive soccer, we observe that the average player at this level is exposed to high-congested game schedules with a mean of 60 competitive games played per season, equating 5.5 games per month [14] or one game every 4.3 days [15]. Consequently, a lot of physical and psychological stress is imposed on professional soccer players [9, 16]. Players participating in two games per week and less than or equal to four recovery days are under a substantial risk of sustaining an injury. It is estimated that it is more than six times higher, compared to having only one game per week and a recovery time of six days or more between competitions [17–19]. Imposing load without enough recovery might also be an essential factor leading to illnesses or injuries [20,21]. Among other performance factors in soccer, repeated sprint ability, jumping ability, maximal strength seem to be reduced immediately after a game; and the time needed to recover from training sessions or competitive events fully may vary between 48 hours and 96 hours depending on the authors and the physical fitness values analyzed [18,22–30]. Besides, biochemical markers in team sports are also altered inconsistently after training or competition, showing relevant differences in the recovery profile of every sport [31]. Particularly in soccer, CK and hormonal parameters seem the most relevant biomarkers of the recovery process [32]. Establishing the importance of recovery, several studies show non-significant differences in injury risk, running performances, or pace in technical activities during congested competitive PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 2 / 20 Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. periods in professional soccer players [33,34]. Soccer players seem to be able to cope with the physical demands of consecutive games [34–37]. Thus, the decline in performance can be attributed to an increase in game interruptions and not to the effect of physical fatigue, and it may be a common trend to overestimate fatigue-induced performance declines [35]. Player’s covered distances and velocities also show dependency on contextual game factors such as the venue and the result of the game [36]. To experience transient residual fatigue over the games and the season is something common in professional soccer players, causing adverse effects on the on-field physical performance and predisposing to overuse and non-contact injuries [18, 37–40]. Minimizing the effects of travel fatigue should also be taken into account [41], given that traveling long distances by plane has a significant effect on the subjective ratings of jet-lag, neurological fatigue, and sleepiness [42]. The knowledge about physical performance profiles, players management (squad rotation) recovery strategies, and time courses seems to be an essential factor in getting a realistic approach to recovery, establishing an optimal periodization design for the season, and optimizing players’ readiness for the upcoming competitions. [16,33,38,43–46]. To enhance the recovery process, the more common strategies employed by athletes include ergogenic aids, hydrotherapy, active recovery, stretching, compression garments, and massage [47,48]. These methods are frequently used by professional soccer players, being nutrition, sleep, compression garments, cold-water immersion, and contrast water therapy, the ones with a better subjective perception [49]. However, in many cases, scientific evidence is not taken into account before implementing these strategies, showing inadequacies of sports science knowledge translation to the day-to-day practice [4]. Abaïdia and Dupont [50] proposed a practical recovery protocol based on an extensive scientific revision, finding a high grade of recommendation for several nutritional strategies and hydration, cold water immersion, whole-body cryotherapy, and compression garments. In this proposal, other recovery strategies such as sleep, massage, foam rolling, electrical stimulation, and massage were considered inappropriate, or its benefits in physical performance and recovery were not clear. Moreover, other authors concluded that even active strategies were largely ineffective for improving postexercise recovery, offered some benefits compared with passive ones [51,52]. Specifically, in soccer, some studies show that active recovery neither has effects on neuromuscular recovery nor in antioxidant response to competitive games and muscle soreness [27, 45,53]. Others found it useful, reducing muscle pain, concluding that it may help to restore performance abilities such as vertical jump [54]. Cold-water immersion is another of the most common strategies employed and has been reported as effective improving muscular damage and discomfort and overall fatigue perception after training and competition, but not having a definite positive effect on physical performance [55–58]. Modern techniques, such as electrostimulation and foam roller, have also shown a significant effect on the recovery in agility and perceived muscle soreness [59,60] while compression garments have reduced histological damage in some experimental studies [61]. However, the studies with professional or semiprofessional soccer players are scarce, and consequently, decision making very complex. Several authors have tried to find pooled positive effects of using combinations of different recovery strategies. Kinugasa & Kilding [62] observed higher positive effects on perceived recovery after combining cold-water immersion and active recovery. In another study, wholebody vibration (WBV), in combination with a traditional cool-down reduced perceived muscle pain and enhanced recovery faster than the protocols without WBV after a soccer-specific drill [10]. Other authors have demonstrated that no recovery strategy is more effective than the others. However, the use of combined strategies tended to be more effective than a simple strategy [63]. To the best of our knowledge, no systematic review has analyzed the empiric use of these strategies in professional soccer settings previously. PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 3 / 20 Therefore, the main aim of the present study is to review the available evidence on the value of post-match recovery strategies and interventions in male professional or semi-professional soccer players in order to determine its effect on post-match performance outcomes, physiological markers, and wellness indicators. Materials and methods Design A systematic review and meta-analysis focusing on the effects of different recovery strategies in professional soccer contexts were reported following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) [64]. Before the search, a review protocol based on PRISMA-P [65] was completed (S1 File) and registered at PROSPERO (ID = CRD42018094854). The review protocol was updated during the review process and is available at http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID= CRD42018094854 (07 November 2019) Search strategy and study selection A systematic computerized literature search was performed using six online databases: Medline (PubMed), Scopus, SPORTDiscus, WOS (Web of Science), CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL). The search included articles published before May 20 th , 2020. All databases were searched using Boolean operators with the following medical subject headings (MeSH) and free text words for critical concepts related to recovery and soccer performance: “Athletes,” “Sport,” “Recovery,” “Match,” “Performance,” “Feeling perception.” The eligibility of the studies was formulated according to the following PICOS criteria, which returned relevant articles in the field using a snowballing approach: • Population: elite professional or semi-professional male football or soccer players. • Intervention: structured interventions comparing methods and control groups. • Comparison: studies that compare different recovery modalities or between a modality and control group. • Outcomes: physical performance was taken into account as a primary outcome. Subjective perception, wellness, technical, tactical, and physiological performance were considered as secondary outcomes. • Study design: randomized clinical trials were included. Studies were included if 1) were randomized controlled trials (RCTs) with participants randomly separated into equal groups (control group and intervention group); 2) participants were semi-professional or professional adult football/soccer players; 3) recovery strategies were performed after a competition. Studies were excluded if: 1) female players were taken into account. Only full-text publications in English were considered. The complete search strategy for each database can be found in the S2 File. The searches were customized to accommodate the layout and characteristics of each search tool. The reference sections of all identified articles were examined, and a hand-search of it was also conducted for other potentially relevant references. One author selected papers for inclusion (AAB). Titles and abstracts obtained by the search were screened and downloaded into Mendeley Desktop (Glyph & Cog) for a subsequent fulltext review. Cross-references and duplicates were removed. All publications potentially relevant for inclusion in the meta-analysis were independently assessed by two reviewers (AAB PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 4 / 20 and JVB). Any discrepancies at this stage were resolved during a consensus meeting, and a third (JP) reviewer was available if needed. Outcome variables For the primary outcome, changes in muscle strength, sprint and jump performance values obtained from different tests after using recovery modalities were considered. For the secondary outcomes, changes in psychological, wellness, and physiological data were considered. Data extraction General study information, participants, intervention characteristics, and outcome measures were extracted independently by two reviewers (AAB and JVB) using a specific standardized data extraction form (S3 File). When studies provided insufficient data for inclusion in the meta-analysis, the first author of the study made contact with the corresponding author(s) to determine whether additional data could be provided; in other cases, data was extracted from graphs using Digitizeit digitizer software (https://www.digitizeit.de). Risk of bias Methodological quality was not implemented, as no evidence for such appraisals and judgments exists and, therefore, can be confusing when interpreting results [66]. A bias is a systematic error, or deviation from the actual effect, in results or inferences. The authors assessed the risk of bias in RCTs following the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials [67]. The items on the list were divided into six domains: selection bias (random sequence generation, allocation concealment); performance bias (blinding of participants and researchers); detection bias (blinding of outcome assessment); attrition bias (incomplete outcome data); reporting bias (selective reporting); and other bias. For each study, bias domain was judged by consensus (AAB and JVB), or third-party adjudication (JPL) and was characterized as “high” (a plausible bias that severely weakens confidence in the results); “low” (a plausible bias unlikely to seriously alter the results); or “unclear” (plausible bias that raises some doubt about the results). A quote from the study report, together with a justification for the judgment, was provided. Statistical analysis Descriptive data of the participants’ characteristics were reported as mean (SD). All meta-analyses calculations were conducted with the R software with meta and metafor packages for metanalysis (Version 3.5.1.). Descriptive analyses and figures of risk of bias were performed using Microsoft Excel for MAC, version 16.29.1 (Microsoft, USA). Mean and standardized mean differences (Hedges’ g) and 95% CI for each group were calculated. The analysis of pooled data was conducted using a random-effect model [68] to estimate the change for each group at the same measurement time on primary and secondary outcomes. For the secondary meta-analysis, the mean difference between primary and secondary outcomes was collected to estimate the change from baseline to each time measurement for each group (control and experimental groups). Standardized mean differences were weighted by the inverse of the variance to calculate the size of the effect and 95% confidence interval. Cohen’s criteria were used to interpret the magnitude of the effect: <|0.50|: small; |0.50| to |0.80|: moderate; and >|0.80|: large [69]. Heterogeneity was assessed using Cochran’s Q statistics and its corresponding p-value as well as the I 2 statistic, which describes the percentage of variability in effect estimates attributable to PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 5 / 20 heterogeneity rather than chance when I 2 was >30% (30–60% representing moderate heterogeneity) [66]. Publication bias was assessed with funnel plots and Begg’s test. Significance was set at p<0.05. In the case of studies reporting recovery at different time frames such as 20h and 44h, those values were assimilated to the ones reported in the literature, 24h and 48h. Results The initial search identified 4184 references (Fig 1). No other references were identified through the examination of reference lists and citations of relevant articles. After the identification of duplicates, 3402 titles and abstracts were screened. Seven studies remained for further full-text analysis. Subsequently, 2 studies were excluded. The reasons for exclusion were that participants were not football or soccer players; or data on primary outcomes (performance) was not assessed in the study. In the end, five studies were included in the final review process. Fig 1. Eligibility flow diagram showing the selection process for the inclusion studies in this meta-analysis. n: sample size. https://doi.org/10.1371/journal.pone.0240135.g001 PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 6 / 20 Description of studies Five RCTs [57,70–73] were included in this review, with their most relevant characteristics being summarized in Table 1. A total of 69 participants were included in the review, with a mean age of 20.8 ±1.3 years with a range of 18 to 28 years The competitive level of the soccer players in the studies was semi-professional [57,71–73], and elite or professional [70]. From the included studies, three assessed the effects of wearing lower-body compression garments Table 1. Characteristics of the included randomised controlled trials. Study Population and level N (male); age ±SD Intervention description Group: Intervention and Control characteristics Primary Outcome Secondary outcomes Results, conclusions and intervention effect Ascensão et al. [57]. 20 junior soccer players National team leagues IG (10); 18.1 ±1.8 years CG (10); 18.3 ±0.8 years Effect of immediate postexercise CWI single session on soccer players After match for 10 minutes IG: CWI 10ºC CG: TWI 35ºC SJ (cm) CMJ (cm) 20-m sprint (sec) MVIC (Kg) DOMS Muscle damage: CK (U/L), Mb (μg/L) Inflammation CRP (mg/L) Decrease in SJ at 24h and CMJ at 24h and 48h in the TWI group b Decrease in CMJ at 24h in the CWI group b Decreases in peak quadriceps strength in the TWI group at 24h and 48h and in CWI at 48h b Quadriceps strength greater at 24h in CWI group a CWI more effective than TWI at 24h for quadriceps and calf DOMS and at 30min for hip adductors a CK increased in both groups at 30min, 24h and 48h b and more in the TWI at 24h and 48h a Mb increased in both groups at 30min b , more in the TWI a CRP concentrations increased in both groups at 30min and 24h b , but again more in the TWI than in CWI a Clifford et al. [70]. 11 elite professional soccer players 19.0 ±1.0 years Effect of wearing lower body garments fitted with cooled phase changed material (PCM) on accelerating functional and perceived recovery after a game 45 min after match for 3 hours. 5 mmHg IG: PCMcold 15ºC CG: PCMwarm 22ºC CMJ (cm) MVIC (N) BAM+ MS BFQ MVIC at 36 h and 60 h post was greater with PCMcold than PCMwarm a MS post 36 h and 60 h was lower with PCMcold than PCMwarm a No differences in CMJ or BAM + between groups. PCMcold was more effective than the PCMwarm after the intervention according to BFQ a Fullagar et al. [71]. 20 highly trained semiprofessional soccer players 25.5 ±4.6 years Effect of an acute sleep hygiene strategy (SHS) on physical and perceptual recovery of players after a late-night game. IG: SHS lights dimmed, eyemasks and ear plugs, cool temperature rooms (~17˚C). No technological or light stimulation ~15–30 min prior to bedtime. 7h 30 min in bed. CG: NSHS allowed to use mobile phones and TV. 5 h 30 min in bed. External load Internal load CMJ (cm) YYIR2 (m) Objective and subjective sleep data General recovery state Sleep chronotype RPE Psychological recovery Physiological recovery Muscle damage: CK (mg/ml) and urea(mg/dl) Inflammation: CRP (mg/dl) Greater sleep duration in SHS compared to NSHS on match night a Less sleep duration with NSHS b Greater wake episodes on match night for SHS a No differences between conditions for any physical performance or venous blood marker. Maximum heart rate during YYR2 higher in NSHS than SHS at 36h a No differences between conditions for perceptual “overall recovery” or “overall stress. (Continued) PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 7 / 20 [70,72,73], one assessed the effects of cold-water immersion [57] and one assessed the effects of an acute sleep hygiene strategy [71] on performance outcomes. One of the compression garments interventions [70] combined compression with cold, using specific garments with cooled phase changed material (PCM) at 15º. All the studies assessed the effects of recovery strategies at 24 hours and 48 hours post-match. Since only one of the authors [72,73] reported the effects of recovery strategies at 72 hours, those values could not be included in the analyses. Some authors were contacted to provide extra information about the studies. Data from three authors could be obtained [70,72,73], two were extracted from the tables and graphs Table 1. (Continued) Study Population and level N (male); age ±SD Intervention description Group: Intervention and Control characteristics Primary Outcome Secondary outcomes Results, conclusions and intervention effect MarquésJiménez et al. [72]. 18 semiprofessional soccer players 24.0 ±4.07 years Evaluate physiological and physical responses to wearing compression garments during soccer matches and during recovery During game and during 3 days after for 7 h/day. SG: 20–25 mmHg ankle / 15–20 mmHg calf FLG: 25–30 mmHg calf / 15–20 mmHg thigh QG: 15–20 mmHg thigh CG: no compression garments CMJ (cm) 10–20 m sprint (sec) T-Test (sec) YYIR2 (m) [La-] mmol/L SaO 2 (%) RPE TQR There are significant correlations, immediately postmatch, between 10-m sprint and 20-m sprint in the CG, 10-m sprint and 20-m sprint and 10-m sprint and T-Test in the SG, and [La-] and 10-m sprint in the QG. At 48 h post-match, there are significant correlations between 10-m sprint and 20-m sprint in the EG, 10-m sprint and 20-m sprint in the SG, 10-m sprint and 20-m sprint in the FLG. At 72 h post-match there are significant correlations between 10-m sprint and 20-m sprint in the CG. MarquésJiménez et al. [73]. 18 semiprofessional soccer players 24.0 ±4.07 years Evaluate the influence of different types of compression garments in reducing exerciseinduced muscle damage (EIMD) during recovery after a friendly soccer match During game and during 3 days after for 7 h/day. SG: 20–25 mmHg ankle / 15–20 mmHg calf FLG: 25–30 mmHg calf / 15–20 mmHg thigh QG: 15–20 mmHg thigh CG: no compression garments EIMD biomarkers DOMS Swelling In CG, most biomarkers, including CK, LDH, GOT and GPT, were greater at 72-h postmatch compared to pre-match. In EG, increases a between preand 72-h post-match were observed only in CK and LDH. Thigh swelling increases a with time were present in CG. Differences in calf swelling were observed between CG, EG, SG and FLG a DOMS differences between groups were only observed between CG, SG and QG in tibialis soreness, between CG and FLG in quadriceps soreness, between CG, EG, SG and QG in calf soreness and between SG and QG in hamstring soreness IG: intervention Group; CG: control group; EG: Experimental group; CWI: cold water immersion; TWI: thermoneutral water immersion; SJ: squat jump; CMJ: counter movement jump; MVC: maximal voluntary contraction; DOMS: delayed onset muscle soreness; CK: creatine kinase; Mb: myoglobin; CRP: C-reactive protein; PCM: cooled phase change material; MIVC: maximal isometric voluntary contraction; BAM+: brief assessment of mood; MS: muscle soreness; BFQ: belief questionnaire; SHS: sleep hygiene strategy; NSHS: normal post-game sleep hygiene strategy; YYIR2: Yo-Yo intermittent recovery level 2; RPE: rate perceived exertion; SG: stockings group; FLG: tights group; QG: shorts group; TQR: perceived recovery; [La-]: lactate concentration; SaO 2 (%): Arterial oxygen saturation of hemoglobin; EIMD: exerciseinduced muscle damage; LDH: lactate; GOT: glutamic oxaloacetic; GPT: glutamic pyruvic a Significance at p<0.05 b Significant differences at baseline level (p<0.05) https://doi.org/10.1371/journal.pone.0240135.t001 PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 8 / 20 [57,71]. Results of the RCTs risk of bias assessment are presented in Table 2 and Fig 2. The primary source of bias was the blinding of participants and outcome assessors. Total estimate Primary analyses. Four RCTs [57,70–72] were included in the primary analyses for primary outcomes. In total, six analyses were performed: two for CMJ (24h and 48h), two for the 20-m sprint (24h and 48h), and two for MVC (24h and 48h), are shown in Table 3 and Fig 3. For the CMJ, the results showed no difference at 24h (MD = 1.26; 95% CI: -0.92 to 3.44; p = 0.2575; I 2 = 0.0%; SMD = 0.14; 95% CI: -0.31 to 0.59), but greater CMJ values at 48h for the intervention group (MD = 3.01; 95% CI: 1.21 to 4.80; p = 0.001; I 2 = 10.4%; SMD = 0.69; 95% CI: 0.14 to 1.25). For the 20-m sprint, the results showed no difference either at 24h (MD = -0.05; 95% CI: -0.14 to 0.04; p = 0.311; I 2 = 0%; SMD = -0.28; 95% CI: -0.81 to 0.24), or 48h (MD = -0.02; 95% CI: -0.10 to 0.06; p = 0.592; I 2 = 28.1%; SMD = -0.21; 95% CI: -0.74 to 0.31). For the MVC, the results showed no difference either at 24h (MD = -105.41; 95% CI: -189.14 to 399.97; p = 0.483; I 2 = 90.4%; SMD = 0.57; 95% CI: -1.10 to 2.25), or 48h for the intervention group (MD = 36.21; 95% CI: -42.58 to 115.01; p = 0.3677; I 2 = 0%; SMD = 0.23; 95% CI: -0.38 to 0.84). No heterogeneity was present (I 2 range from 0 to 28.1%) in all the analyses, except for MVC at 24h (I 2 = 90.4%). Finally, analyses on aerobic capacity (YYIR2) could not be performed due to lack of available data. Secondary analyses. Three RCTs [57,71,73] were included in the secondary analyses for the secondary outcomes (physiological markers and wellness data). In total, nine analyses were performed: one for CK, two for CRP (at 24h and 48h), two for quadriceps (QUAD), hamstrings (HAMS), and calf (CALF) DOMS (at 24h and 48h) are shown in Table 3. Table 2. Risk of bias (RCTs). Study Domain Random sequence generation Allocation concealment Blinding of participants and researchers Blinding of outcome assessment Incomplete outcome data Selective reporting Other bias Ascensão et al. [57]. Low Unclear High Unclear Low Low - Clifford et al.[70]. Low Low Low Unclear Low Low Low Fullagar et al. [71]. Low Unclear High Unclear Low Low Low Marqués-Jiménez et al. [72]. Low Unclear High Low Low Low Low MarquésJiménez et al. [73]. Low Unclear High Unclear Low Low Low https://doi.org/10.1371/journal.pone.0240135.t002 Fig 2. Risk of bias (RCTs). https://doi.org/10.1371/journal.pone.0240135.g002 PLOS ONE Recovery strategies in elite male soccer players: A systematic review and meta-analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0240135 October 2, 2020 9 / 20 Data curation: Albert Altarriba-Bartes, Javier Peña, Jordi Vicens-Bordas, Raimon MilàVillaroel. Formal analysis: Albert Altarriba-Bartes, Javier Peña, Jordi Vicens-Bordas, Raimon Milà-Villaroel, Julio Calleja-Gonza ´lez. Investigation: Albert Altarriba-Bartes, Javier Peña, Jordi Vicens-Bordas, Julio CallejaGonza ´lez. Methodology: Albert Altarriba-Bartes, Javier Peña, Jordi Vicens-Bordas, Raimon Milà-Villaroel, Julio Calleja-Gonza ´lez. Software: Raimon Milà-Villaroel. Supervision: Albert Altarriba-Bartes, Javier Peña, Jordi Vicens-Bordas, Julio Calleja-Gonza ´lez. Validation: Albert Altarriba-Bartes, Javier Peña, Jordi Vicens-Bordas, Julio Calleja-Gonza ´lez. Visualization: Albert Altarriba-Bartes, Javier Peña, Jordi Vicens-Bordas. 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