SaveYourself.ca • Sensible advice for aches, pains & injuries
updated 2/03/12
Massage reduces inflammation and promotes recovery after intense exercise? No! The study that made headlines in February 2012 was absurdly exaggerated by the researchers, the media, and massage therapist bloggers. Read more…
Delayed-onset muscle soreness (DOMS) or “muscle fever” — such a wonderfully descriptive term — is that distinctive muscle pain that nearly everyone experiences after intense or unfamiliar exercise, often peaking as much as a day or two later. Sometimes it is so severe that it is mistaken for a pulled muscle. Weakness is a symptom as much as the pain is, but only hardened competitors are likely to test their strength while feeling so sore. 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 regime. When I was a Registered Massage Therapist, patients often came to me hoping for treatment, or some advice on how to avoid the condition. It was often the primary reason given for a massage appointment: “Help, I’m sore from my workout!”
Alas, there was nothing1 I could do for them. It’s 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 adequate evidence or justification. Like most health care myths, it’s not too loudly touted, just carelessly repeated and perpetuated (often in major publications, ahem2). But medical science cannot even explain DOMS, let alone stop it — it seems to be nature’s little tax on exercise, which everyone must pay. There are no shortcuts through it. DOMS is indomitable.
The cause of DOMS is unknown, although it is generally described as the consequence of mechanical and/or metabolic stress3 … which isn’t saying much. What else would cause DOMS? Financial stress?
Unfortunately, nothing more specific can be said about the roots of DOMS with any confidence. “Microtrauma” certainly gets said anyway, but it’s just another way of saying mechanical stress. While it does seem plausible that intense exercise could cause microtrauma specifically — and the idea is prevalent — the evidence does not strongly support this idea, and some research actually contradicts it.45
“Metabolic stress” is much less frequently brought up. The notion here is that muscle cells are like little chemical factories, and they produce some unpleasant by-products when operating 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.67
For demonstration purposes, we’ll dip into the complexity of this subject on just one point. “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].”8 Unfortunately, although free radicals have a great name, which sounds just exactly 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.”9 In other words, they may be involved — they probably are involved — but the relationship is indirect and unclear at best. They could even simply be a byproduct of some other, hidden culprit.
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,10 ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms.”11 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”25 — 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 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,2627 although — disappointingly — they are not actually resolving it, and they definitely do not reduce the muscle weakness that goes with it. 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. And the value of anti-inflammatory medication as prevention for DOMS has been challenged by studies showing no benefit to that usage at all, a contradiction of an extremely prevalent athletic belief!28 Evidence even indicates that there is little or no inflammation present in DOMS.29 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,30 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 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 impressive — and some evidence contradicts the claim, including my own careful personal testing (see next section). Massage as a DOMS treatment is also often “explained” with a huge myth — that massage detoxifies — which calls into question the credibility of the claim. No better explanation has ever really been offered until just recently.
As of early 2012, there’s a candidate for a new explanation … or 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 minor, and generally over-interpreted the significance of a handful of proteins. I analyze the evidence in detail in a separate article,31 but the upshot is that it’s much ado about nothing and doesn’t really change our understanding of massaging DOMS. 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.
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.32 Ernst concluded that, “Massage therapy may be a promising treatment for DOMS. Definitive studies are warranted.”33 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 of 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.34 A 2008 review found “moderate data supporting its use” — wow — continuing the pattern of damning it with faint praise, and pulling a barely-positive conclusion out of weak data.35 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).36 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, even when it does and probably never will, it’s difficult to even propose how massage therapy is supposed to help. While it does seem likely that massage therapy probably has some positive effect on DOMS — a placebo, if nothing else — 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, and 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.
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 and therefore 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.
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 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!
BACK TO TEXT Comments: 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 Comments: 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 BACK TO TEXT BACK TO TEXT Comments: From the abstract: “Increased muscle temperature [by ultrasound] failed to provide significant prophylactic effects on the symptoms of DOMS.” BACK TO TEXT Comments: 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 Comments: 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.” BACK TO TEXT Comments: 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.” BACK TO TEXT Comments: A small study showing no effect of ice massage on muscle soreness after exercise. The massage was not very “massage-y,” but massage for DOMS is also tainted somewhat by this evidence. BACK TO TEXT Comments: 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. The implication of this is that icing may interfere with normal post-exercise muscle physiology, and prevent the process of muscles adapting to stress. I am not aware of any other research on this topic, but I will certainly keep an eye out for it. BACK TO TEXT BACK TO TEXT Comments: From the abstract: “… analysis indicated no statistically significant differences between massage, microcurrent electrical stimulation, upper body ergometry, and control groups.” BACK TO TEXT BACK TO TEXT Comments: 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.” BACK TO TEXT Comments: 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.” BACK TO TEXT Comments: This experiment tested the effect of ibuprofen on hard-core marathoners. There were 29 ultra-marathoners on high doses of ibuprofen and 25 controls that completed the race without meds. There was no measurable difference in muscle damage or soreness between the two groups. Lead researcher David Niemen: “There is absolutely no reason for runners to be using ibuprofen.”
Comments: 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 ….” BACK TO TEXT Comments: 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.” BACK TO TEXT Comments: 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 proteins, 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.
Comments: From the article: “An effective treatment has been sought for many years … to date, none of these approaches has been fully convincing.” BACK TO TEXT BACK TO TEXT Comments: 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.