They’re expensive, they’re trendy, and the pros swear by them—but do compression boots really improve athletic performance? When we looked at the academic research on this topic, it was hard to find extensive evidence to support the use of compression devices in relation to athletic performance. So we asked two USA Triathlon certified coaches, Hector Torres (arguing the case for) and Susan Sotir (arguing the case against), to highlight the benefits and pitfalls. But first, let’s define exactly what compressions boots are and what they claim to do.
Compression devices: What are they?
A pneumatic compression device (PCD) is an inflatable garment for the arms or legs that includes a pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary by use and user setting.
Before they became popular in the sporting world, they had long been used in the medical world. These devices can be prescribed by doctors and are often covered by insurance for specific medical uses. For example, PCDs are often used post-surgery when a person is bed-ridden. They help to keep edema (swelling caused by excess fluid trapped in body tissues) in check. Other times they are prescribed for people with lymphedema or when people have lower extremity venous insufficiency that can cause dermatitis, chronic edema, and venous ulcers. The risks of using a PCD are rare and include pressure injuries, nerve damage, and skin breakdown.
It can be argued that insurance companies wouldn’t cover a device unless it is proven to help patients recover and avoid other more costly procedures. Does this argument transfer to athletic performance? Do pneumatic compression devices help athletes reduce inflammation, recover from workouts, and improve performance?
Why use compression boots?
Rest, ice, compression, and elevate (RICE) has been the go-to standard for many years to help recovery of an injury (Blahd et al.) However, pneumatic compression has helped take this to the next level. Pneumatic compression device (PCD) technologies are widely used to aid the reduction of lymphedema and for the prophylaxis of deep vein thrombosis. However, use is not as extensive when working with athletic populations (Waller et al.) Athletes have been using PCDs to promote blood flow and by doing so eliminating metabolic waste and allowing the athlete to recover faster and get back into the field. The effectiveness of pneumatic compression is that it augments venous and arterial blood flow via the inflation of each chamber of the attachment, such as the legs (Blahd et al.).
Many companies offer different compression methods, such as sequential compression and Hyperice Normatec Pulse technology. There are differences in these technologies.
Sequential compression devices are plastic wraps that are placed around a patient’s legs in order to decrease the chance of blood clot formation. They have compartments that inflate and deflate, gently squeezing the muscles of the legs (Pitto et al.). Almost all these devices provide static compression.
The Hyperice NormaTec Pulse uses three key technologies to maximize recovery: pulse, gradient and distal release.
Instead of using static compression (squeezing) to transport fluid out of the limbs, the pulse technology uses dynamic compression. The patented pulsing action more effectively mimics the muscle pump of the legs and arms, greatly enhancing the movement of fluid and metabolites in the limbs after an intense workout (Sands et al.).
Veins and lymphatic vessels have one-way valves that prevent fluid backflow. Devices such as NormaTec boots hold pressure to prevent fluid from being forced in the wrong direction. Because of this enhancement, instead of tapering pressure off, models such as the Pulse and Pulse Pro can deliver maximum pressure in every zone (Sands et al.). Many athletes report feeling reduced soreness after tough workouts when using devices such as NormaTec boots, especially when doing higher volume back-to-back days.
Because extended static pressure can be detrimental to the body’s normal circulatory flow, the pulse technology releases the hold pressures once they are no longer needed to prevent any backflow (distal release.) By releasing the holding pressure in each area as quickly as possible, each part of the limb gets maximum rest without noticeable pauses between compression cycles (Kephart, W. et al). All of this combines to enhance what the body naturally does, but just takes it to the next level in order to maximize recovery and help the athlete do the thing they love the most—get back out there training the next day.
The downsides of compression boots and devices
Exercise is defined as a planned deviation from homeostasis, intentionally engaging in activity that results in disruptions to body temperature, blood flow, and to the metabolic and mechanical behaviors of working tissues. After a bout of exercise, we experience a period of continued disruption, which signals the system to either restore and repair exactly what was there before or, when we train regularly, to repair and improve on the system’s ability to meet the new demands we keep imposing. Without repeated exposures to this inflammatory response, there is no change (Kellman et al., 2018; Peake et al., 2015).
PCDs reduce inflammation, which sounds terrific, but it also means that when PCDs are used after exercise, the time and magnitude of inflammation the body experiences are reduced, potentially attenuating the gains from training. Therein lies the rationale for the argument against them: We just don’t know. The research literature around PCD use and chronic adaptations is not robust. Few studies of endurance athletes completing endurance related tasks exist and, when they do, the methodological challenges are substantial if we want to draw cause-and-effect conclusions.
Draper et al. (2020) had well-trained runners (five female, five male) complete two 20-mile runs at 70% VO2max. Each runner completed both runs, three to four weeks apart, and was randomly assigned to the order of the recovery conditions (PCD use for one hour after running or no directed recovery modality). No differences were identified for post-run muscle soreness or C-Reactive protein levels (indicators of inflammation).
This study highlights the challenges of systematically and rigorously assessing the use of PCDs with endurance athletes. Training was not controlled before, during, or after. Hydration status, nutrient intake, and sleep were neither tracked nor controlled. Placebo effects were not addressed. The timeline was such that normal physiological adaptations could have occurred for some of the athletes. If we are looking for evidence-based support for or against the use of PCDs in endurance athletes, we need more cause-and-effect level evidence to inform our decision making.
In my opinion, use the tool when it is the right tool for the job. When activity is particularly stressful (long or intense) or is followed closely by another session that is also stressful or important for psychological, physical, or race-specific preparation, use the PCDs to serve your goals. Most days, seek to build the adaptations wanted within the natural constraints your body and life allow, but know that there is a scarcity of data to back up the benefits of these devices. If you have the discretionary budget to spend on these devices and they force you to take some downtime with your feet kicked up, perhaps there is benefit.
Our compression experts
Gale Bernhardt has coached Olympians and professional and recreational endurance athletes for years. Some want to go faster, some want to cross the finish line, while others simply want endurance sport as a lifestyle. She provides ready-to-use, easy-to-follow training plans for cycling and triathlon.
Hector L. Torres holds two masters degrees in Sport & Fitness with a concentration in Sport Leadership and Coaching from the University of Central Florida and a Masters in Health Science from the Rocky Mountain University of Health Professionals. He has over 19 years experience helping athletes succeed. More information can be found here.
Susan Sotir has a Ph.D. in Sport and Exercise Psychology from Springfield College, is a USA Triathlon Level III coach, is a certified strength and conditioning coach (NSCA-CSCS) and is a Precision Nutrition Certified Coach. She has over 25 years of experience in sport, coaching, and education. Find out more about Susan here.
References, Hector Torres
Blahd, William H, et al. as medical reviewers, “Rest, Ice, Compression, and Elevation (RICE),” University of Michigan Health Guidelines, Michigan Medicine, 9 Mar. 2022.
Kephart, Wesley C, et al. “A single bout of whole-leg, peristaltic pulse external pneumatic compression upregulates PGC-1a mRNA and endothelial nitric oxide synthase protein in human skeletal muscle tissue,” The Physiological Society, Experimental Physiology, 11 May 2015.
Pitto, R P, et al. “Hemodynamics of the lower extremity with pneumatic foot compression.
Effect on leg position,” Biomedizinische Technik. Biomedical Engineering, U.S. National Library of Medicine, 1 May 2001.
Sands, William A, et al. “Dynamic compression enhances pressure-to-pain threshold in elite athlete recovery: exploratory study.” Journal of Strength and Conditioning Research,
U.S. National Library of Medicine, 29 May 2015.
Sands, William A, et al. “Peristaltic pulse dynamic compression of the lower extremity enhances flexibility,” The Journal of Strength & Conditioning Research., Apr. 2014.
Waller, Tom, et al. “Intermittent pneumatic compression technology for sports recovery.” SpringerLink, Springer New York, 1 Jan. 1970.
References, Susan Sotir
Rapassi, L., et al. “The effect of the intermittent pneumatic compression (CPI) method in triathlon athletes: a literature review,” Revista CPAQV – Centro de Pesquisas Avançadas em Qualidade de Vida – CPAQV Journal, 12(1), 2020.
Draper, S. N., et al. “Effects of intermittent pneumatic compression on delayed onset muscle soreness (DOMS) in long distance runners,” International Journal of Exercise Science, 13(2), 75, 2020.
Kellmann, M., et al. “Recovery and performance in sport: consensus statement,” International Journal of Sports Physiology and Performance, 13(2), 240-245, 2018.
O’Donnell, S., et al. “The effect of intermittent sequential pneumatic compression on recovery between exercise bouts in well-trained triathletes. Journal of Science and Cycling, 4(3), 19-23, 2015.
Peake, J. M., et al. “Modulating exercise-induced hormesis: does less equal more?” Journal of Applied Physiology, 119(3), 172-189, 2015.
Sheldon, R. D., et al. “Acute impact of intermittent pneumatic leg compression frequency on limb hemodynamics, vascular function, and skeletal muscle gene expression in humans,” Journal of Applied Physiology, 112(12), 2099-2109, 2012.
Winke, M., et al. “Comparison of a pneumatic compression device to a compression garment during recovery from DOMS,” International Journal of Exercise Science, 11(3), 375, 2018.
Zuj, K. A., Prince, et al. “Enhanced muscle blood flow with intermittent pneumatic compression of the lower leg during plantar flexion exercise and recovery.” Journal of Applied Physiology, 124(2), 302-311, 2018.
