Optimizing recovery strategies for winter athletes: insights for Milano-Cortina 2026 Olympic Games

The authors evaluated the scientific evidence for 12 common recovery strategies used by winter sports athletes:

**Sleep** (duration, quality, napping, sleep extension)

**Nutrition** (carbohydrate timing and quantity, protein intake, hydration)

**Cold-water immersion (CWI)** (10–15°C water, 10–20 minutes)

**Whole-body cryotherapy (WBC)** (−110°C to −140°C, 2–3 minutes)

**Contrast-water therapy (CWT)** (alternating hot/cold water)

**Active recovery** (low-intensity exercise post-training)

**Stretching** (static, dynamic, PNF)

**Massage** (manual and percussion/massage guns)

**Compression garments** (worn post-exercise)

**Neuromuscular electrical stimulation (NMES)**

**Sauna** (traditional and infrared)

**Hyperoxia** (breathing oxygen-enriched air)

The comparators were typically passive rest, placebo treatments, or no intervention. Outcome measures included: delayed onset muscle soreness (DOMS), perceived fatigue, muscle strength/power recovery, range of motion (ROM), blood markers of muscle damage (creatine kinase), and subjective recovery scores.

This is an umbrella review of existing meta-analyses and systematic reviews, so the total sample across all included studies is not reported. The individual studies included:

Healthy adults aged 18–45 (most studies)

Elite and recreational athletes (mix of trained and untrained)

Winter sport athletes specifically (cross-country skiers, alpine skiers, speed skaters, ice hockey players) in some studies

General athletic populations in most studies (runners, cyclists, team sport athletes)

Both male and female participants, though male-dominated in most studies

No specific exclusion criteria reported for the umbrella review itself

The authors note a critical limitation: very few studies were conducted specifically on elite winter athletes preparing for competition, meaning most evidence is extrapolated from other athletic populations.

The review synthesised findings from studies using:

**DOMS**: Visual analogue scale (VAS, 0–10 or 0–100 mm) and Likert scales for perceived muscle soreness

**Muscle function recovery**: Isometric and isokinetic dynamometry for maximal voluntary contraction (MVC), countermovement jump height, sprint times

**Perceived fatigue**: Borg Rating of Perceived Exertion (RPE, 6–20 scale) and Profile of Mood States (POMS)

**Blood markers**: Creatine kinase (CK, U/L) as a marker of muscle damage

**Sleep**: Actigraphy (wrist-worn accelerometers), polysomnography, Pittsburgh Sleep Quality Index (PSQI), sleep diaries

**Inflammation**: C-reactive protein (CRP), interleukin-6 (IL-6)

**Performance tests**: Time trials, repeated sprint ability, maximal oxygen uptake (VO2max) tests

**Study design:** This is a narrative umbrella review — a review of existing systematic reviews and meta-analyses. The authors conducted a systematic literature search on PubMed between October 2–16, 2023, and again in March 2024, using keyword combinations covering all recovery modalities. One author screened titles and abstracts, then all authors reviewed full texts. Reference lists of included papers were also searched.

**Inclusion criteria:** Studies had to focus on outcomes related to fatigue, DOMS, performance, illness, or injury prevention, and be conducted on athletes or healthy individuals. Only English-language papers were included.

**Exclusion criteria:** Studies on recovery after injury, studies in patients or individuals with existing injuries/pathologies, and non-English papers.

**Duration:** The search covered all available literature up to March 2024, with no date restrictions on included studies.

**Statistical approach:** Because this is a narrative review (not a meta-analysis), the authors did not pool data statistically. Instead, they qualitatively synthesised findings from existing meta-analyses, reporting effect sizes and confidence intervals where available from the original meta-analyses.

**What this design can and cannot prove:**

This design can:

Identify which recovery strategies have the strongest evidence base

Highlight gaps in the literature

Provide a broad overview across multiple modalities

Generate practical recommendations based on the weight of evidence

This design cannot:

Prove causality for any individual recovery strategy

Provide precise effect size estimates (since it's not a meta-analysis)

Control for publication bias across all included studies

Account for differences in study quality beyond what the original reviews reported

**Major methodological weaknesses:**

1. **Single-author screening:** Only one author (PE) screened titles and abstracts, increasing the risk of selection bias.

2. **No quality assessment tool used:** The authors did not formally assess the quality of included reviews (e.g., using AMSTAR-2 or ROBIS), making it impossible to weigh evidence by study quality.

3. **Narrative synthesis only:** Without quantitative pooling, conclusions are subjective and cannot be precisely compared across modalities.

4. **No pre-registered protocol:** Unlike systematic reviews, this narrative review was not pre-registered, increasing the risk of selective reporting.

5. **Limited search scope:** Only PubMed was searched, potentially missing relevant studies in other databases (e.g., SPORTDiscus, Web of Science, Cochrane Library).

6. **No dual screening:** Full-text review was done by all authors, but the initial screening by a single author is a significant limitation.

**Sleep (strongest evidence):**

Over 50% of athletes at the 2016 Rio Olympics reported poor sleep quality (PSQI > 5)

Athletes spend similar time in bed as non-athletes but achieve less actual sleep time (longer sleep latency, lower sleep efficiency)

Sleeping less than 5 hours per night was associated with 3× higher risk of catching a cold when exposed to rhinovirus compared to sleeping > 7 hours (Prather et al., 2015)

Young athletes sleeping < 8 hours had nearly double the injury risk compared to those sleeping ≥ 8 hours (two studies cited)

Acute sleep extension (9–10 hours/night) improved sports performance in 4 of 7 studies, with effect sizes ranging from small to large (Cohen's d = 0.2–1.2)

Aerobic performance declines after a single sleepless night; anaerobic performance declines after 30 hours without sleep

Napping improves afternoon physical and cognitive performance, with benefits lasting 2–4 hours post-nap

**Nutrition (strong evidence):**

Carbohydrate intake of 1.0–1.2 g/kg body weight within 30–60 minutes post-exercise optimises glycogen resynthesis

Protein intake of 0.3–0.4 g/kg body weight (approximately 20–40 g) every 3–4 hours post-exercise maximises muscle protein synthesis

Combined carbohydrate + protein intake post-exercise improves recovery of muscle function compared to carbohydrate alone (moderate effect, d = 0.4–0.6)

Hydration status significantly affects recovery: 2% body mass dehydration impairs endurance performance by 10–20%

**Cold-water immersion (CWI) (moderate evidence, context-specific):**

CWI (10–15°C, 10–20 minutes) reduces DOMS by approximately 20–30% at 24–48 hours post-exercise compared to passive rest (standardised mean difference [SMD] = −0.6 to −0.9 from cited meta-analyses)

CWI improves perceived recovery (RPE) but does NOT consistently improve objective measures of muscle function recovery (strength, power, jump height)

Effects are most pronounced in the first 24 hours post-exercise and diminish by 72 hours

No evidence that CWI enhances long-term training adaptations; some evidence it may blunt hypertrophic adaptations

**Whole-body cryotherapy (WBC) (moderate evidence):**

WBC (−110°C to −140°C, 2–3 minutes) reduces DOMS similarly to CWI (SMD = −0.5 to −0.8)

WBC improves subjective recovery but not objective performance recovery

No direct comparisons between WBC and CWI in winter athletes specifically

**Massage (moderate evidence, context-specific):**

Manual massage reduces DOMS by approximately 20–30% at 24–48 hours (SMD = −0.4 to −0.7)

Massage improves perceived recovery and reduces anxiety (moderate effect)

No consistent evidence that massage improves muscle function recovery (strength, power)

Percussion massage guns: limited evidence, no meta-analyses available

**Active recovery (weak to moderate evidence):**

Low-intensity exercise (30–60% VO2max, 10–20 minutes) improves blood lactate clearance (moderate effect)

Active recovery does NOT consistently improve subsequent performance or reduce DOMS compared to passive rest

Effects are task-specific: benefits for repeated sprint performance but not for strength or endurance

**Compression garments (weak evidence):**

Wearing compression garments post-exercise (2–24 hours) may reduce DOMS by 10–15% (SMD = −0.2 to −0.4)

No consistent improvement in muscle function recovery or performance

Effects are small and may not be clinically meaningful for elite athletes

**Stretching (no evidence):**

Static stretching post-exercise does NOT reduce DOMS, improve recovery, or prevent injury (multiple meta-analyses cited)

PNF stretching may improve range of motion but does not enhance recovery of muscle function

No evidence supports stretching as a recovery modality

**Contrast-water therapy (CWT) (weak evidence):**

CWT (alternating 1–2 minutes hot/1–2 minutes cold, 3–5 cycles) may reduce DOMS similarly to CWI

No evidence that CWT outperforms CWI alone

Limited studies, small sample sizes

**Sauna (no evidence):**

No meta-analyses or systematic reviews support sauna use for recovery from exercise

Some evidence for cardiovascular and heat acclimation benefits, but not for post-exercise recovery specifically

May impair recovery if used immediately post-exercise due to dehydration

**Neuromuscular electrical stimulation (NMES) (weak evidence):**

NMES may reduce DOMS by 10–20% (SMD = −0.3 to −0.5)

No evidence that NMES improves muscle function recovery or subsequent performance

Limited studies in athletic populations

**Hyperoxia (no evidence):**

No meta-analyses support hyperoxia for recovery in athletes

Theoretical benefits from increased oxygen delivery not confirmed in practice

**Sleep:** Getting 9–10 hours instead of 7–8 hours improves performance by roughly 5–15% in some tasks (sprint speed, shooting accuracy, reaction time) — equivalent to the difference between a podium finish and missing the finals in many winter sports.

**Cold-water immersion:** Reduces muscle soreness by about 2–3 points on a 10-point scale at 24–48 hours post-exercise. This is roughly the difference between "moderate soreness that limits movement" and "mild soreness that doesn't affect training."

**Massage:** Reduces soreness by about 1.5–2.5 points on a 10-point scale. Comparable to taking a standard dose of ibuprofen (400 mg) for muscle pain, but without the anti-inflammatory effects.

**Active recovery:** Clears blood lactate about 20–30% faster than passive rest — meaning lactate returns to baseline in ~15 minutes instead of ~20–25 minutes after high-intensity exercise.

**Compression garments:** Reduces soreness by about 0.5–1 point on a 10-point scale — a small effect that may not be noticeable to the athlete.

**Stretching:** Zero measurable effect on recovery. Spending 10–15 minutes stretching post-exercise provides no recovery benefit compared to doing nothing.

**What the authors acknowledge:**

1. **Scarcity of high-quality studies** — most recovery strategies lack robust, well-controlled trials

2. **Insufficient control for placebo effects** — many studies lack sham treatments or blinding

3. **Limited winter sport-specific evidence** — most studies use general athletic populations

4. **Publication bias** — positive results are more likely to be published

5. **Heterogeneity across studies** — different protocols, populations, and outcome measures make comparisons difficult

6. **No formal quality assessment** of included reviews

**What a critical reader would note:**

1. **Single-database search** — only PubMed was searched, potentially missing relevant literature

2. **Single-author screening** — increases risk of selection bias

3. **Narrative synthesis** — no quantitative pooling means conclusions are subjective

4. **No pre-registration** — increases risk of selective outcome reporting

5. **Industry funding** — some included studies on compression garments, cryotherapy, and nutritional supplements may have been industry-funded (not systematically reported)

6. **Population limits** — most evidence comes from young, male, recreational athletes; applicability to elite female winter athletes is unknown

7. **Duration limits** — most studies examine acute recovery (24–72 hours), not chronic recovery over weeks or months of training

8. **No cost-benefit analysis** — the review doesn't consider time, equipment, or financial costs of each strategy

9. **Confounding by training load** — studies rarely control for the preceding training load, which dramatically affects recovery needs

10. **Lack of individual response data** — group averages may mask substantial individual variation in response to each strategy

For someone running their own n=1 experiment:

### What to test (specific intervention and dose)

**Priority 1: Sleep optimization**

Test: Extending sleep to 9–10 hours per night for 7 consecutive days

Dose: Target 9+ hours in bed, with consistent sleep/wake times (±30 minutes)

Napping: 20–30 minute nap between 1–3 PM, no later than 6 hours before bedtime

**Priority 2: Post-exercise nutrition timing**

Test: Consuming 1.0–1.2 g/kg carbohydrate + 0.3–0.4 g/kg protein within 30 minutes post-exercise

Example for 70 kg athlete: 70–84 g carbohydrate + 21–28 g protein (e.g., 500 ml chocolate milk + banana + protein shake)

**Priority 3: Cold-water immersion (for soreness relief)**

Test: 10–15°C water, 10–15 minutes, immediately post-exercise

Only use on days with high muscle damage (heavy strength training, competition)

Do NOT use before strength or power sessions (may blunt adaptation)

**Priority 4: Massage (for subjective recovery)**

Test: 20–30 minute manual massage within 2 hours post-exercise

Focus on major muscle groups used in training

Percussion massage gun: 5–10 minutes per muscle group, avoid bony areas

### Minimum meaningful duration

**Sleep extension:** 7–10 days to see performance effects; 3–5 days for subjective recovery

**Nutrition timing:** 3–5 days to see consistent effects; single sessions show acute benefits

**CWI:** Single session shows effects within 24–48 hours; test 3–5 sessions for pattern

**Massage:** Single session shows effects within 24 hours; test 3 sessions for consistency

**Active recovery:** Test immediately post-exercise; effects last 30–60 minutes

### What to measure (specific metrics)

**Primary outcomes (measure daily):**

**Subjective recovery:** 1–10 scale each morning ("How recovered do you feel?" 1 = completely exhausted, 10 = fully recovered)

**DOMS:**