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Delayed Onset Muscle Soreness (DOMS)

The mysteries of muscle fever, nature’s little tax on exercise

6,500 words, updated Dec 11th, 2013
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

Muscle fever — such a wonderfully descriptive term — is that distinctive muscle pain that nearly everyone experiences after intense or unfamiliar exercise, often peaking as long as a day or two later. Because of the delay, it is best known as DOMS — delayed-onset muscle soreness.1 Sometimes DOMS is so severe that it is mistaken for a pulled muscle. Read on for one of the most detailed readable articles about DOMS available online.

Muscle fever is an appropriate term because it makes your muscles feel sickly as well as sore. Weakness is a significant and objectively measurable symptom — but only hardened competitors are likely to test their strength while feeling so sore and gross. The nastiness starts after a bit of a delay, often after sleeping, and then continues for 24 to 72 hours. Some people don’t even notice it until the second day.

DOMS is annoying and style-cramping, particularly if you’re starting or restarting an exercise regimen. When I was a Registered Massage Therapist, patients often hoped for DOMS relief, or some advice on how to avoid it.3

Alas, there was nothing4 I could do for them. It’s mostly a myth that DOMS can be effectively treated by massage…or anything else. Believe me, I’ve tried — my personal experimentation will be described below. Massage therapists certainly often claim to be able to do so, but without evidence or justification. Like many health care myths, it’s not too loudly touted, just carelessly repeated and perpetuated (often in major publications, *cough*5). But medical science can barely even explain DOMS, let alone treat it — it seems to be nature’s little tax on exercise, which everyone must pay. There are no shortcuts through it. DOMS is indomitable.

About footnotes. There are many footnotes in this document. Click to make them “pop up” without losing your place. There are two types: interesting extra content, and boring reference information.1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.
Try one!

What triggers delayed-onset muscle soreness?

Exercise or other physical stresses outside your normal range of intensity. How far? That seems to depend on many unknown factors. Exactly what it takes to make people exactly how sore is one of the main mysteries of DOMS. But some things are fairly certain:


Dancing fool

Maybe the worst DOMS I ever had was after a night of dancing and, yes, a little “head banging.” (I grew up in a Canadian logging town; AC/DC and Metallica were like gods to us.) Even a little head banging can be hard on neck muscles. I could barely lift my head off my pillow for 3 days.

Dancing fool

Maybe the worst DOMS I ever had was after a night of dancing and, yes, a little “head banging.” (I grew up in a Canadian logging town; AC/DC and Metallica were like gods to us.) Even a little head banging can be hard on neck muscles. I could barely lift my head off my pillow for 3 days.

The (unclear) causes of delayed-onset muscle soreness

The exact cause of DOMS is unknown, although it is generally described as the consequence of mechanical and/or metabolic stress7 … which isn’t saying much. What else would cause DOMS? Financial stress?

In broad strokes, DOMS is probably a mild form of poisoning called “rhabdomyolysis” — or just “rhabdo” for short (and for the rest of this article). True rhabdo is a medical emergency in which the kidneys are poisoned by myoglobin from muscle crush injuries.8 But many physical and metabolic stresses cause milder rhabdo-like states — including intense exercise, and probably the strongest massage as well.9 There are many well-documented cases of exertional or “white collar” rhabdo.10 That term was coined by Knochel in 1990 because rhabdo was striking recreationally extreme athletes — people with white-collar jobs who voluntarily work themselves into a sorry state.11 Rhabdo often strikes recreationally extreme athletes, people who voluntarily work themselves into a sorry state. You could also call it (for fun) recreational rhabdo. Another well-known source of rhabdo cases is military boot camp: “large numbers of [recruits] may have myoglobinemia….”12 After a bit of browsing through the literature, I have the impression that you could be rhabdo-ized by an especially hard sneeze.

The mildest rhabdo — a comparatively benign cocktail of waste metabolites and by-products of tissue damage — is probably one of the reasons why we feel generally cruddy after intense physical stresses.

But although “rhabdo” is a fun word, it doesn’t really say much. We know remarkably little about the biology of that state.13 Surprisingly little specific can be said about how DOMS works. For instance, “microtrauma” certainly gets said anyway, but it’s just another way of saying mechanical stress. And while it does seem plausible that intense exercise could cause microtrauma specifically — and the idea is prevalent, and it is probably involved to some extent — the research does not support this idea nearly as well as you might assume, and some even contradicts it.1415

What about metabolic stress?

“Metabolic stress” is a more sophisticated way of looking at the cause of DOMS. Muscle cells are like little chemical factories, and they produce some unpleasant by-products — and probably more of them when working at intensities they haven’t had a chance to adapt to. It seems plausible enough in general terms, but it’s a tricky concept to pin down.

What constitutes metabolic stress, exactly? Researchers have spent decades identifying various obscure molecules produced by cells during exercise, but are any of these molecules necessarily a sign of painful metabolic wear and tear? Just because a cell produces a substance during exercise does not mean it is metabolically frazzled, or that you are going to hurt. In any event, no one has been able to find a link between DOMS and any specific biological markers.1617

For demonstration purposes, we’ll dip into deeper into this subject on just one molecule. “Free radicals” or “reactive oxygen species” are unstable, highly reactive molecules that are an unavoidable by-product of cellular metabolism. “There is growing evidence that reactive oxygen species (ROS) are involved in [DOMS].”18 Unfortunately, although free radicals have an even better name than “rhabdo,” which sounds just nasty enough to cause DOMS, they don’t have the decency to actually be present in great numbers when DOMS is at its worst. Instead, “the increase [of free radicals] occurred after the peak decline in muscle function and DOMS.”19 In other words, ROS may be involved — they probably are involved — but the relationship is indirect and unclear at best. They could even simply be a by-product of some other, hidden culprit.

And then there’s neurology!

Neurology never comes up when professionals talk DOMS. It’s really not on anyone’s radar. But it probably should be.

We’ve established that DOMS isn’t exactly a direct result of microtrauma or metabolic stress. It is obviously more complicated than it seems on the surface, and nothing demonstrates that more clearly than an 2011 study, which showed that it can actually spread — probably via a neurological mechanism — to adjacent muscles groups that were not exercised at all.20

That’s really very strange. Very strange indeed. Thus DOMS may well often feel much worse and more extensive to some patients than it “should” feel … and with an explanation that isn’t really on anyone’s radar.

The biology of pain is never really straightforward, even when it appears to be.

“Reconceptualising pain according to modern pain science”, Lorimer Moseley

The (unknown) cures for delayed onset muscle soreness

Since we don’t (yet) know what causes DOMS, it’s unsurprising that anything like a cure has yet to be discovered, or even anything that is significantly helpful. Even if we understood it, we still might not be able to do anything about it. Certainly nothing tried so far seems to be the least bit impressive. For instance, a 2003 review of the subject concluded, “Cryotherapy, stretching, homeopathy,21 ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms.”22 Other reviews have similarly dismissive conclusions.23 Here’s a list of popular but unconvincing treatments, with relevant evidence for each in the footnotes:

There are few treatments that have a modicum of positive evidence associated with them. For instance, everyone will be pleased to know that one study (predictably European) showed some benefits to hot tubbing, specifically “warm underwater jet massage”40 — aaaah. However, it was a small and flawed piece of research — and most people know from personal experience that a soak in a hot tub may “take the edge off it,” but this hardly constitutes a miracle cure for DOMS.

“Vitamin I” may also be partially useful. Ibuprofen (and other anti-inflammatory drugs) have been shown to reduce the pain of DOMS,4142 although — disappointingly — they are not actually resolving it, and they definitely do not reduce the muscle weakness that goes with it. If you had severe DOMS in your quadriceps, taking ibuprofen would probably reduce your pain, but you would still not be able to jump as high as usual.In short, they are masking the pain, not treating the condition. For instance, if you had severe DOMS in your quadriceps, taking ibuprofen would probably reduce your pain, but you would still not be able to jump as high as usual.

The value of anti-inflammatory medication as prevention for DOMS has been challenged by studies showing no benefit to that usage at all — a sharp repudiation of an extremely prevalent athletic belief! For instance, a 2006 experiment tested the effect of ibuprofen on hard core marathoners.43 The results were so strongly at odds with beliefs that Christie Aschwanden used the research as a main example in an article about how hard it is to get people to accept new evidence:44

Among runners of ultra-long-distance races, ibuprofen use is so common that when scientist David Nieman tried to study the drug’s use at the Western States Endurance Run in California’s Sierra Nevada mountains he could hardly find participants willing to run the grueling 100-mile race without it.

Nieman, director of the Human Performance Lab at Appalachian State University, eventually did recruit the subjects he needed for the study, comparing pain and inflammation in runners who took ibuprofen during the race with those who didn’t, and the results were unequivocal. Ibuprofen failed to reduce muscle pain or soreness, and blood tests revealed that ibuprofen takers actually experienced greater levels of inflammation than those who eschewed the drug. “There is absolutely no reason for runners to be using ibuprofen,” Nieman says.

The following year, Nieman returned to the Western States race and presented his findings to runners. Afterward, he asked whether his study results would change their habits. The answer was a resounding no. “They really, really think it’s helping,” Nieman says. “Even in the face of data showing that it doesn’t help, they still use it.”

Fascinating!

Evidence even indicates that there is little or no inflammation present in DOMS in the first place.45 And it’s possible that anti-inflammatory medications could even interfere with recovery, as with ice.

Generally speaking, there is a broad consensus that nothing really decisively helps DOMS,46 and the best way to prevent it is … just get it over with. In other words, only DOMS prevents DOMS!

But what of massage therapy? We’ve got to deal with massage in more detail, because it’s the king of presumed treatments.

Massage, DOMS, and a lot of irony

Oh, irony

Massage can cause some soreness and malaise, rather than relieving it.

Massage therapists and enthusiasts often claim DOMS prevention and cure as a benefit of massage. Unfortunately, what evidence there is to support this damns it with faint praise — it doesn’t work well enough to be impressive47 — and some evidence goes the other way, including my own careful personal testing. At best, massage has mild therapeutic effects on DOMS that are largely mitigated or cancelled out by mild side effects.

It’s more likely that massage actually causes some soreness and malaise itself — just like exercise does. The sensations are incredibly similar.

A 2007 survey of 100 massage patients48 found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. This would mainly be the familiar slight soreness that is common after a massage, known as “post-massage soreness and malaise” (PMSM) — and although 10% is plenty, it is almost certainly too small a number.49

But the irony deepens! Massage as a DOMS treatment is also often “explained” with a myth — that massage detoxifies. This is an unsavory association. Detox language in health care is usually bollocks. In the case of massage, the detoxification claim never made much sense, there’s no evidence for it, and if anything there’s evidence that massage is somewhat toxifying — probably by causing a little rhabdo. I make that case in a lot of detail in another article:

Is there any hope? Some other way that massage could help DOMS? Even while possibly causing some at the same time? No explanation other than detoxification has ever been suggested … until just recently.

Can massage reduce DOMS by reducing inflammation?

No. You can go to the next section now, if you like. As of early 2012, there’s a candidate for a new explanation of how massage works … or a new myth. It’s a lot more likely that it’s a new myth.

According to the headlines and the researchers themselves, massage supposedly “reduces inflammation,” based on a gene profiling experiment that got a lot of press. (A lot.) It’s bollocks. Unfortunately, the researchers tried to explain a therapeutic effect that is either an illusion or a minor outcome, and they generally over-interpreted the significance of a handful of proteins. The upshot is that it’s much ado about nothing and doesn’t really change our understanding of massaging DOMS.50

Although this fact was distinctly under-emphasized, the study identified literally hundreds of changes in gene expression caused by exercise — compared to just five changes caused by massage. The take-home message from that is simple: exercise changes cellular behaviour, massage does not. That is not really any kind of a surprise.

Enough theory! Does massage help DOMS or not?

We don’t have to know how something works to test to see if it works. And massage for DOMS has been tested. The upshot is that the results are mixed and underwhelming. Damned with faint praise.

In 1998 — around the time I was starting my training as a massage therapist, actually — E. Ernst published a review of papers on this subject in the British Journal of Sports Medicine.51 Ernst concluded that, “Massage therapy may be a promising treatment for DOMS. Definitive studies are warranted.”52 That sounded like good news for massage therapy! However, actually reading the paper discouraged me.

Digging into the details always seems to have that effect.

Ernst found only seven studies worth considering, and most of these had “serious methodological flaws” and “very small sample sizes.” Of the seven, three are inconclusive or show no effect on massage therapy on DOMS, and four “imply a positive symptomatic effect” or a “positive trend.” I was not particularly impressed by any of those positive effects or trends — they all seemed ambiguous to me, even if you ignore the “serious methodological flaws.” I could not come to the same optimistic-sounding conclusion that Mr. Ernst did.

Since that time, I have not seen any new studies or evidence to alter my opinion. Another review in 2003 judged massage to be “less promising” than anti-inflammatories, which are themselves so unremarkable.53 A 2008 review found “moderate data supporting its use” — wow — continuing the pattern of damning DOMS-massage with faint praise, and pulling a barely-positive conclusion out of weak data.54 Readers have been telling me for years now that they believe there is new evidence that “massage works” for DOMS, but when I go looking, I can’t find any data that seems the least bit impressive. I acknowledge that some of the evidence is indeed “positive,” but it fails to impress.For example, one the best studies I could find, a 2006 paper by Zainuddin et al, found barely statistically significant evidence of modest pain relief only, possibly quite brief, with no effect on the weakness whatsoever (no study has ever found that).55 And that’s roughly as good as it gets. When people tell me that there is “good evidence” that massage is effective for DOMS, this is what they’re talking about. I acknowledge that some of the evidence is indeed “positive” — that is undeniable — but it fails to impress.

Since we don’t know much about what causes DOMS, and we don’t know much about how massage therapy works (and probably never will), it’s difficult to even guess about how massage therapy is supposed to help. While it does seem likely that massage therapy probably has some positive effect on DOMS, those effects are likely to be limited, and to vary widely depending on the therapist, the individual, and the circumstances. And so I remain skeptical that massage therapy can be claimed to generally prevent or reduce the intensity of DOMS, let alone actually “cure” it. Massage therapy should not be promoted or purchased for this reason. Fortunately, there are other reasons to have massage therapy: see Does Massage Therapy Work? A review of the science of massage therapy … such as it is.

From the Lab of Me: an experiment with a sample size of one

Purpose: To test massage-aided recovery from delayed onset (post-exercise) muscle soreness. Systemic steam heating — I have a lovely steam room at my disposal — was used as an adjunctive therapy.

Methods: I totally thrashed my biceps at the gym, deliberately pushing into the danger zone to generate wicked DOMS. It worked a charm: my guns were mighty sore by the end of the day. Soreness spiked with the slightest contraction, making it easy to evaluate. The next morning, sensitivity was equally savage on both sides. In a toasty steam room, I massaged the crap out of my left upper arm for several minutes, using strong deep palm stroking, which was super unpleasant. The things I do for science! Then I compared soreness at regular intervals by flexing simultaneously.

Results: Soreness in my biceps was identical at all testing points after massage: 5 and 20 minutes later, and about 1, 6, 12, 24, 36, 48 and 72 hours later. The soreness was extremely intense from 24 to 48 hours, fading quickly after that — the usual pattern of recovery. And entirely symmetrical.

Conclusion: Neither strong massage or heat produced any effect on DOMS in this little guinea pig.

The role of insomnia and sleep disturbance in DOMS

Losing sleep is a major factor in pain, muscle pain in particular, and probably DOMS as well. There is no direct scientific evidence of this that I am aware of. However, anyone who has ever been severely sleep deprived will tell you that it causes a distinctive and unpleasant feeling of “fragility” which seems quite likely to make one more vulnerable to DOMS.

Ultimate is an intense Frisbee sport that can make almost anyone wicked sore.

I have an example of sleep-deprivation induced DOMS from the laboratory of me.

The first ultimates games of the season have always been an ordeal. They are followed by 3-5 days of harsh DOMS. But in 2011 I started the season in unusually good physical condition, thanks to months of sprint intervals and strength training. For the first time ever, I was not sore after my first games of the summer. And my DOMS-immunity continued in week two, so it didn’t seem to be a fluke.

That was then followed by some nasty sleep deprivation and jet lag. I suffered a great deal of it for two weeks — before, during and after a holiday to Amsterdam. When I returned to Vancouver and played ultimate again, I was really blasted sore. Quite extreme.

Coincidence? I think not!

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Further Reading

Appendix: Dueling massage anecdotes: A typical testimonial versus my own personal experiment with massage for delayed-onset muscle soreness

In early 2012 I made one of my once-in-a-while appearances on SkepticNorth.ca. I’m in their roster of reserve guest myth busters. This time Scott Gavura (the Skeptical Pharmacist) recruited me early one morning for some short-notice debunkery of a sloppy Globe & Mail piece on delayed onset muscle soreness (DOMS). I felt like the Batman getting the bat signal, but instead of being a billionaire martial artist gadget freak called to fight crime, I’m a middle-class amateur athlete gadget freak called on to fight … bad science journalism. An endless chore. Just like Batman’s.

The Globe & Mail recommended Epsom salts, massage, and light exercise for muscle soreness. None of those will do anything or much, just like every other alleged treatment for DOMS. As covered thoroughly in this article, there really is no cure for DOMS but time. Inevitably, we saw some anecdotal evidence to the contrary in the comments. OCTriathlete stood up for massage with this story:

I was lucky enough to receive a leg massage from a family member who is educated in massage but not a professional. However, I was unlucky in that the massage was interrupted after only one leg was complete!! The next day the leg that received the attention was only hinting at the sensation of the heavy workout the previous day. The leg that missed out? It was DEEPLY sore for 2 days. So there you have it- my own little scientific (however unintentional) experiment

Lucky him! I’ve done that experiment intentionally and casually a half dozen times in my life before getting a little more serious about it — see the section “From the Lab of Me” — and I’ve never observed the slightest difference. If only. And in the early days I did it with the greatest of optimism and the full-on mental bias of someone paying his rent by selling that therapy. I love massage for many reasons, but recovering from a harsh workout has never been one of them.

O anecdote — how I want strangle thee

I wonder what would happen if we took Occam’s razor to OCTriathlete’s anecdote. What is more likely?

I know which bullet point I’d bet on.

Maybe OCTriathlete truly got a benefit. I’m being very skeptical, yes, but I’m not actually saying that he couldn’t have actually enjoyed a nice effect. Physiology differs. The evidence on massage for DOMS isn’t entirely negative — just mostly, and distinctly underwhelming where it’s positive. The history of anecdotal evidence has given us almost every silly belief you have ever heard of: every naked superstition and outrageously dangerous quackery has had its zealots, converts, and emphatic testimonials, sometimes in extremely large numbers.There could be interesting cases on the edge of that bell curve, and OCTriathelete could be one of them — slightly pulling up an unimpressive average.

But … Occam’s razor cuts hard and deep on a story like his.

If anecdotal evidence were actually reliable, then most folk medicine would still be the best medicine available today. If there are a lot of testimonials for something, people like to say that there “must be something to it,” but not only is that not true, it’s practically the opposite of true: testimonials are actually a sign of the wrong kind of thinking about medicine. The history of anecdotal evidence has given us almost every silly belief you have ever heard of: every naked superstition and outrageously dangerous quackery has had its zealots, converts, and emphatic testimonials, sometimes in extremely large numbers. People have sworn that snake oils work even as they were being (literally) destroyed by them. For a whole bunch of wonderfully entertaining examples, spend a happy hour listening to Caustic Soda’s terrific Quackery episode.

And what are those all beliefs are based on? Exclusively?

Anecdotes!

Perhaps a personal experiment like mine — an antimonial — is a just a little bit of an anecdote antidote. I love massage, but I’m not kidding myself: if it helps DOMS at all, it doesn’t help most people much.

Illustration used with the kind permission of Zach Weiner, of Saturday Morning Breakfast Cereal. Thanks, Zach!

Illustration used with the kind permission of Zach Weiner, of Saturday Morning Breakfast Cereal. Thanks, Zach!

Notes

  1. Post-exercise muscle soreness (PEMS) is probably a better term, but DOMS definitely dominates — you can pretty much use the acronym DOMS as a word unto itself, certainly with health and fitness professionals. I will use it that way for the rest of the article. BACK TO TEXT
  2. Acutely and chronically painful patches of soft tissue are a real phenomenon. However, exactly how the work is still mostly mysterious. Conventional wisdom says they are tiny spasms stuck in a metabolic vicious cycle, but they could also be a more pure neurological problem. So-called “muscle knots” are definitely not knots, and probably not limited to muscle either — it’s just that most of our soft tissues is muscle! BACK TO TEXT
  3. It was rarely (if ever) the main reason for the appointment, however. “Help, I’m sore from my workout!” is not really a common thing for people to say when they book massage appointments. This will come up again below. BACK TO TEXT
  4. Well, not nothing. A gentle, soothing massage can be quite nice when you have bad DOMS. However, the niceness lasts not much longer than the massage itself. BACK TO TEXT
  5. This comment was provoked by a really awful mainstream article about muscle soreness in the Globe and Mail: I’m sore after weight-training. How can I recover? BACK TO TEXT
  6. An eccentric contraction is an interesting type of muscular contraction while lengthening — an apparent contradiction! Eccentric contraction is a bit mysterious, and is known to be harder on muscle. For more information, see Eccentric Contraction: A peculiar bit of muscle physiology. BACK TO TEXT
  7. Pyne. Exercise-induced muscle damage and inflammation: a review. Aust J Sci Med Sport. 1994. PubMed #8665277. BACK TO TEXT
  8. The key indicator molecule is creatine phosphokinase (CPK, which is not myoglobin but a molecule that increases in concentration along with myoglobin). Rhabdo is “official” when kidney damage starts around 20,000 U/I of CPK. Myoglobin itself is not toxic, and can circulate more or less harmlessly through your blood. It doesn’t become a problem until it dissolves in acidic urine in the kidneys, because one of its molecular parts poisons the kidneys on its way through. It’s the kidney damage that particularly makes rhabdo a medical emergency. BACK TO TEXT
  9. Lai et al. Fever with acute renal failure due to body massage-induced rhabdomyolysis. Journal of Nephrology, Dialysis and Transplantation. 2006. PubMed #16204282.

    Interesting, short, and readable story of an elderly man who collapsed after an unusually strong massage.

    BACK TO TEXT
  10. Knochel. Catastrophic medical events with exhaustive exercise: "white collar rhabdomyolysis". Kidney International. 1990. PubMed #2232508. BACK TO TEXT
  11. As opposed to, say, doing it because you’re a peasant farmer and you’re really screwed if you don’t get the harvest in. BACK TO TEXT
  12. Olerud et al. Incidence of acute exertional rhabdomyolysis. Serum myoglobin and enzyme levels as indicators of muscle injury. Archives of Internal Medicine. 1976. PubMed #1275626. BACK TO TEXT
  13. Degrees matter. Ice and steam are both made of the same stuff, but they have fundamentally different properties. Mild rhabdo might be too different from acute rhabdo for the label to be meaningful. BACK TO TEXT
  14. Yu et al. Evidence for myofibril remodeling as opposed to myofibril damage in human muscles with DOMS: an ultrastructural and immunoelectron microscopic study. Histochem Cell Biol. 2004. PubMed #1499133.

    From the abstract: “The myofibrillar and cytoskeletal alterations observed in delayed onset muscle soreness (DOMS) caused by eccentric exercise are generally considered to represent damage. By contrast our recent immunohistochemical studies suggested that the alterations reflect myofibrillar remodeling (Yu and Thornell 2002; Yu et al. 2003).” In other words, these researchers found evidence that what previously looked like microtearing of muscle tissue is actually probably just muscle tissue doing microscopic renovations — an adaptive process, not a repair process, and probably not painful in and of itself.

    BACK TO TEXT
  15. Malm et al. Leukocytes, cytokines, growth factors and hormones in human skeletal muscle and blood after uphill or downhill running. Journal of Physiology. 2004. PubMed #14766942.

    From the abstract: “Eccentric physical exercise (downhill running) did not result in skeletal muscle inflammation 48 h post exercise, despite DOMS and increased CK.” Inflammation is the hallmark of tissue damage, so this evidence tends to suggest that muscles are not damaged by hard, unfamiliar exercise.

    BACK TO TEXT
  16. Ibid. More from the abstract: “It is suggested that exercise can induce DOMS by activating inflammatory factors present in the epimysium before exercise. Repeated physical training may alter the content of inflammatory factors in the epimysium and thus reduce DOMS.” The italics are mine. Inflammatory “factors” refer to molecules that mediate inflammatory processes, and note that these are not “metabolites” (products of metabolism). Activating them does not necessarily mean that an inflammatory process occurs, just that they may be implicated in DOMS pain. These researchers believe that DOMS may be related to molecules that are present before exercise, not after — or, more likely, to a combination of molecules present before and after — which suggests that “metabolic stress” is almost certainly much more complex than simply finding the molecule, or even the set of molecules, that cause pain after hard exercise. It’s much more likely to be dependent on several variables over time, which means that we’ll need pictures of muscle chemistry, and not just metabolites, before and during exercise and throughout the onset and resolution of DOMS, before we’ll get a clear idea about what might constitute “metabolic stress.” BACK TO TEXT
  17. See also the discussion of metabolic complexity in Should You Drink Water After Massage? BACK TO TEXT
  18. Close et al. Eccentric exercise, isokinetic muscle torque and delayed onset muscle soreness: the role of reactive oxygen species. Eur J Appl Physiol. 2004. PubMed #1468586. BACK TO TEXT
  19. Ibid. BACK TO TEXT
  20. Ayles et al. Vibration-induced afferent activity augments delayed onset muscle allodynia. Journal of Pain. 2011. PubMed #21665552.

    For this study, young men exercised one leg hard enough to make it good and sore. Pressure pain thresholds and sensitivities were measured a day later in the sore muscles, but also in other muscles that send their sensory information to the same part of the spinal cord — that’s unexercised and non-sore muscles on the sore side, that just happen to be connected to the same area of the spinal cord.

    Not surprisingly, pain thresholds were lower in the sore, exercised muscles. But — and this is cool — vibrating the sore muscles caused soreness in other muscles that should not have been sore! So soreness effectively “spread” to other muscle groups, via the central nervous system. This raises interesting questions about how people with brain-regulated pain dysfunction might react to exercise soreness: could the pain spread to unaffected areas by the same mechanism? It seems likely.

    BACK TO TEXT
  21. It’s pretty silly that this one was tested! BACK TO TEXT
  22. Cheung et al. Delayed onset muscle soreness: treatment strategies and performance factors. Sports Medicine. 2003. PubMed #12617692. BACK TO TEXT
  23. Torres et al. Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: systematic review and meta-analysis. Physical Therapy in Sport. 2012. PubMed #22498151. BACK TO TEXT
  24. Hasson et al. Effect of pulsed ultrasound versus placebo on muscle soreness perception and muscular performance. Scandinavian Journal of Rehabilitation Medicine. 1990. PubMed #2263920. BACK TO TEXT
  25. Brock et al. Effects of deep heat as a preventative mechanism on delayed onset muscle soreness. Journal of Strength & Conditioning Research. 2004. PubMed #14971967.

    From the abstract: “Increased muscle temperature [by ultrasound] failed to provide significant prophylactic effects on the symptoms of DOMS.”

    BACK TO TEXT
  26. Rodenburg et al. Warm-up, stretching and massage diminish harmful effects of eccentric exercise. International Journal of Sports Medicine. 1994. PubMed #8002121.

    Although the title sounds positive about massage, the article is actually much less optimistic: results were equivocal, showing that the treatment regimen had some benefits, but was conspicuously ineffective when it came to, for instance, reducing pain. “DOMS on pressure ... did not differ between the groups.” Although it’s nice to see that this combination of therapies probably had some beneficial effect, it’s hardly persuasive if they didn’t reduce the pain of DOMS. I think it’s reasonably safe to assume that none of them alone are definitely effective.

    BACK TO TEXT
  27. Ibid. Exercise or “working it out” as a method of reducing DOMS was also studied in the previously cited paper. The method was “upper body ergometry,” which basically uses a machine to exercise the upper body. It had no effect on DOMS. BACK TO TEXT
  28. These are amino acids that allegedly promote recovery from exercise. Lots of athletes take them (and lots of athletes wear scammy Power Balance bracelets, too). This practice is based on faith, not evidence. There are only a few scraps of basic science suggesting the possibility of benefit, absolutely no relevant clinical studies, and a list of problems and side effects. For much more detailed information, see Do “Nutraceuticals” Help Arthritis and other Aches and Pains? Debunkery and analysis of supplements and food-like medicines (nutraceuticals), especially glucosamine, chondroitin, and creatine, mostly as they relate to pain. BACK TO TEXT
  29. Namdar et al. Assessment of the effect of L-glutamine supplementation on DOMS. British Journal of Sports Medicine. 2010.

    “These results suggest that L-glutamine supplementation attenuates DOMS effects, muscle damage and downfall of performance in flexor of hip.” However, it’s a weak study, and I don’t think the results do much more than “suggest”: it was a small experiment, and they measured range of motion only (not pain or strength, both of which would have been better choices — DOMS does not particularly limit range of motion, just makes it uncomfortable). Nevertheless, this is a shred of evidence that glutamine might, possibly, help with DOMS a little.

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  30. Lund et al. The effect of passive stretching on delayed onset muscle soreness, and other detrimental effects following eccentric exercise. Scandinavian Journal of Medicine & Science in Sports. 1998. PubMed #9764443.

    From the abstract: “There was no difference in the reported variables between experiments one and two. It is concluded that passive stretching did not have any significant influence on increased plasma-CK, muscle pain, muscle strength and the PCr/P(i) ratio, indicating that passive stretching after eccentric exercise cannot prevent secondary pathological alterations.”

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  31. Herbert et al. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Database of Systematic Reviews. 2011. PubMed #21735398.

    Does stretching help either before or after exercise to reduce soreness? Nope. This large review of many scientific studies concluded with a clear thumbs down: “The evidence from randomised studies suggests that muscle stretching, whether conducted before, after, or before and after exercise, does not produce clinically important reductions in delayed-onset muscle soreness in healthy adults.”

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  32. Howatson et al. Ice massage. Effects on exercise-induced muscle damage. J Sports Med Phys Fitness. 2003. PubMed #14767412.

    A small study showing no effect of ice massage on muscle soreness after exercise. The massage was not very “massage-y,” but non-ice massage for DOMS is also somewhat tainted by this evidence.

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  33. Torres again: “inconclusive evidence to support the use of cryotherapy,” based on a review of 10 studies. BACK TO TEXT
  34. Yamane et al. Post-exercise leg and forearm flexor muscle cooling in humans attenuates endurance and resistance training effects on muscle performance and on circulatory adaptation. Eur J Appl Physiol. 2006. PubMed #16372177.

    It’s only one study, but … yikes! This fascinating experiment done by Japanese researchers showed that regular icing for a few weeks after workouts resulted in a significant reduction in training effects: ice users didn’t get as strong. This implies that icing may interfere with normal post-exercise muscle physiology and prevent the process of muscles adapting to stress. This is reinforced by Tseng et al.

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  35. Tseng et al. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. Journal of Strength & Conditioning Research. 2013. PubMed #22820210.

    Bad icing news: a small study of icing for severe muscle soreness with “unexpected” results, according to the researchers. It seemed to do more harm than good. The icing victims had higher blood levels of molecules associated with muscle injury, and they felt more fatigued. Icing had no effect on recovery of strength, or any biochemical sign of inflammation. A small study, to be sure, but how good can icing be if it can generate this kind of data?

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  36. Denegar et al. High and low frequency TENS in the treatment of induced musculoskeletal pain: a comparison study. Athletic Training. 1988. PubMed #10957699. BACK TO TEXT
  37. Weber et al. The Effects of Three Modalities on Delayed Onset Muscle Soreness. Journal of Orthopaedic & Sports Physical Therapy. 1994. PubMed #9512831.

    From the abstract: “… analysis indicated no statistically significant differences between massage, microcurrent electrical stimulation, upper body ergometry, and control groups.”

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  38. Adding Epsom salts will not make that hot tub any more effective for your muscle fever. I cover this topic separately, and in great detail, in another article, all about Epsom salts. In a nutshell, using Epsom salts is just a bit of implausible folk medicine — a claim that dissolves into nothing when scrutinized. (If that gets your hackles up, please do jump over to the big salt article for all the details before sending me cranky email.) BACK TO TEXT
  39. There’s no direct evidence about this, but there is some pretty suggestive indirect evidence: in 2011, Schwellnus et al established quite conclusively that there’s no connection between hydration and cramping — the death of (yet another) myth about water. They found that dehydrated triathletes were no more likely to suffer cramps than their soggier comrades. Obviously cramps are not DOMS. It is possible that dehydration increases the risk of one but not the other … but I doubt it, and will err in that direction. More important is that the usual rationale for trying to wash your DOMS away is the painfully vague and biologically illiterate notion of “rinsing” metabolic wastes from your system — it doesn’t make any more sense here than it does in other contexts. See Should You Drink Water After Massage?. BACK TO TEXT
  40. Viitasalo et al. Warm underwater water-jet massage improves recovery from intense physical exercise. Eur J Appl Physiol Occup Physiol. 1995. PubMed #8565975. BACK TO TEXT
  41. Hasson et al. Effect of iboprufen use on muscle soreness, damage and performance: a preliminary investigation. Medicine & Science in Sports & Exercise. 1993. PubMed #8423760.

    From the abstract: “These data indicate that a prophylactic dosage of ibuprofen does not prevent CK release from muscle, but does decrease muscle soreness perception and may assist in restoring muscle function.”

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  42. Tokmakidis et al. The effects of ibuprofen on delayed muscle soreness and muscular performance after eccentric exercise. Journal of Strength & Conditioning Research. 2003. PubMed #12580656.

    From the abstract: “The results of this study reveal that intake of ibuprofen can decrease muscle soreness induced after eccentric exercise but cannot assist in restoring muscle function.”

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  43. Nieman et al. Ibuprofen use, endotoxemia, inflammation, and plasma cytokines during ultramarathon competition. Brain Behav Immun. 2006. PubMed #16554145. BACK TO TEXT
  44. Convincing the Public to Accept New Medical Guidelines: When it comes to new treatment guidelines for breast cancer, back pain and other maladies, it’s the narrative presentation that matters. Aschwanden. www.miller-mccune.com. 2011.

    An excellent article about how hard it is to get people to accept new evidence. In particular, and most relevant to SaveYourself.ca, Aschwanden makes an example of research clearly showing that ibuprofen does not prevent athletes from getting sore muscles (see Nieman 2006).

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  45. Semark et al. The effect of a prophylactic dose of flurbiprofen on muscle soreness and sprinting performance in trained subjects. Journal of Sports Science. 1999. PubMed #10362386.

    Experimenters tortured sprinters’ muscles with a savage workout, and the painful results were identical with or without an anti-inflammatory medication. “In conclusion,” they wrote, “the aetiology of the DOMS induced in the trained subjects in this study seems to be independent of inflammatory processes ….”

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  46. Connolly et al. Treatment and prevention of delayed onset muscle soreness. Journal of Strength & Conditioning Research. 2003. PubMed #12580677.

    This is a review. From the abstract: “To date, a sound and consistent treatment for DOMS has not been established. Although multiple practices exist for the treatment of DOMS, few have scientific support. The reader will note that selected treatments such as anti-inflammatory drugs and antioxidants appear to have a potential in the treatment of DOMS. Other conventional approaches, such as massage, ultrasound, and stretching appear less promising.”

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  47. For instance, a 2012 review by Torres et al, which looked at the results of nine studies of massage, concluded that it is “ slightly effective” but “its mean effect was too small to be of clinical relevance.” BACK TO TEXT
  48. Cambron et al. Side-effects of massage therapy: a cross-sectional study of 100 clients. J Altern Complement Med. 2007. PubMed #17983334. BACK TO TEXT
  49. Researchers would have avoided inflicting painfully strong massage on their subjects, but breathtakingly strong massage is quite common “in the wild.” Other, less specific studies have reported higher rates of complications. Carnes found that 20-40% of all manual therapy treatments — massage, chiropractic, physiotherapy — will cause some kind of unpleasantness: a side effect or “adverse event” in medicalspeak. BACK TO TEXT
  50. Crane et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Science Translational Medicine. 2012. PubMed #22301554.

    This study is the source of a new massage myth that massage reduces inflammation. Inspired by the doubtful notion that “massage may relieve pain in injured muscle” after intense exercise, researchers looked for changes in the proteins that cells constantly make (“gene expression”). They compared muscle tissue samples with and without massage and concluded that “massage therapy appears to be clinically beneficial by reducing inflammation and promoting mitochondrial biogenesis.” Massaged muscle was found to be producing different amounts of five protein related to inflammation and promoting the growth of mitochondria (cell power plants). It was an interesting, technically demanding, and worthwhile experiment, and it’s nifty that there was any difference in gene expression in massaged muscle.

    Unfortunately, the results of this study were actually negative: the data showed that massage has no significant effect on gene expression in muscle cells. There are several major problems with the study: the sample size was extremely small; the number of changes they found was trivial (and dwarfed by what exercise causes); the size of the differences was barely statistically significant—and short-lived, too; they measured genetic “signals” and not actual results, and guessed about their meaning; and we already know from clinical trials that massage doesn’t work any miracles for soreness after exercise, so what is there for the data to “explain”? Despite all of these problems, the results were spun as an explanation for how massage works in general — in the paper itself, the abstract, the journal’s summary, the press release, and interviews. Consequently, the results have been widely reported and discussed as if it is now a scientific fact that massage actually does reduce pain and promote recovery, and the only question was “how?” It’s a debacle.

    For a much more detailed analysis, see Massage does not reduce inflammation and promote mitochondria, or a more technical analysis by Dr. David Gorski at ScienceBasedMedicine.org, Does massage therapy decrease inflammation and stimulate mitochondrial growth? An intriguing study oversold.

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  51. Ernst. Does post-exercise massage treatment reduce delayed onset muscle soreness? A systematic review. British Journal of Sports Medicine. 1998. PubMed #9773168.

    From the article: “An effective treatment has been sought for many years … to date, none of these approaches has been fully convincing.”

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  52. Just as a side note, Dr. Edzard Ernst has become far more skeptical than he used to be. There’s a strong chance that he wouldn’t be so casually optimistic about massage as a DOMS treatment if he were tackling the subject for the first time today. BACK TO TEXT
  53. Connolly et al again: “…anti-inflammatory drugs and antioxidants appear to have a potential in the treatment of DOMS. Other conventional approaches, such as massage, ultrasound, and stretching appear less promising.” BACK TO TEXT
  54. Best et al. Effectiveness of sports massage for recovery of skeletal muscle from strenuous exercise. Clinical Journal of Sports Medicine. 2008. PubMed #18806553. BACK TO TEXT
  55. Zainuddin et al. Effects of massage on delayed-onset muscle soreness, swelling, and recovery of muscle function. Journal of Athletic Training. 2005. PubMed #16284637.

    This is a good representative example of research about massage for DOMS, and notable for how underwhelming it is. After acknowledging that “the findings about the effects of massage on DOMS and muscle function are inconclusive or contradictory in nature,” these researchers muddied the waters still more with their own inconclusive experiment. In an extremely small study comparing 10 massaged arms to their unmassaged twins, “Massage was effective in alleviating DOMS by approximately 30% and reducing swelling, but it had no effects on muscle function.” Those results sound encouraging, and they are to some degree, but there are major caveats. They are barely statistically significant, and one key measure of pain was not: in other words, the results could have been a coincidence. Also, the effect size — a 30% reduction in pain — is just not that great, but especially if it’s temporary … and the researchers don’t say how long it lasted (and yet they did provide graphs of how all their other measurements changed over time). Cynically I wonder if it means that the pain-killing effect was quite brief: wouldn’t it have been a nice thing to report if it had been lasting? It’s an odd omission. Finally, the failure to have any effect on muscle strength is consistent with all other studies of massage for DOMS, and it means that massage is only relieving a little pain at best — not actually “fixing” or promoting recovery.

    Bear in mind that this weak evidence is one of the stronger examples of a “positive” study of massage for DOMS. This is roughly as good as it gets.

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