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.
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:
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
“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.
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
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 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”37 — 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,3839 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.40 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:41
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.”
Evidence even indicates that there is little or no inflammation present in DOMS in the first place.42 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,43 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 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 patients44 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.45
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.
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.46
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.
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.47 Ernst concluded that, “Massage therapy may be a promising treatment for DOMS. Definitive studies are warranted.”48 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.49 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.50 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).51 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.
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.
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.
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!
Interesting, short, and readable story of an elderly man who collapsed after an unusually strong massage.BACK TO TEXT
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
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
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
From the abstract: “Increased muscle temperature [by ultrasound] failed to provide significant prophylactic effects on the symptoms of DOMS.”BACK TO TEXT
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
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
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
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.BACK TO TEXT
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.BACK TO TEXT
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?BACK TO TEXT
From the abstract: “… analysis indicated no statistically significant differences between massage, microcurrent electrical stimulation, upper body ergometry, and control groups.”BACK TO TEXT
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
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
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
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
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 reduces inflammation and promotes 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.BACK TO TEXT
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
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.BACK TO TEXT