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updated 8/14/08

You Can’t Beat DOMS!

The myth of treatment for nature’s little tax on exercise, delayed onset muscle soreness (DOMS)

by Paul Ingraham, Vancouver, Canada MORE

Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.


Delayed-onset muscle soreness (DOMS) is that distinctive muscle pain that everyone experiences after intense or unfamiliar exercise … sometimes so severe that it is sometimes mistaken for a pulled muscle (see Save Yourself from Muscle Strain!). Weakness is a symptom as much as pain is, but only hardened competitors are likely to test their strength while feeling so sore. The nastiness starts after a delay of at least a few hours, often after sleeping, and then continues for 24 to 48 hours. Some people find that the second day after exercising is actually worse, while some don’t even notice DOMS until the second day.

Unfortunately, medical science cannot explain DOMS or stop DOMS — it seems to be nature’s little tax on exercise, which everyone must pay.

The (unclear) causes of delayed onset muscle soreness

The cause of DOMS is unknown, although it is generally described as the consequence of mechanical and/or metabolic stress1 — which isn’t saying much. What else would cause DOMS? Financial stress?

Unfortunately, not much more can be said about the roots of DOMS with any confidence. While it seems plausible, for instance, that intense exercise could cause “microtearing” of muscle tissue — and this is the basis of several theories — the evidence does not strongly support this idea, and some research contradicts it.23

A clear link between DOMS and any particular irritating molecule has yet to be established.

“Metabolic stress” can seem like a plausible explanation for DOMS, but it is a difficult 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 metabolic wear and tear? That can be hard to say. Just because a cell produces a substance during exercise does not mean it is metabolically frazzled. In any event, no one has been able to find a link between DOMS and any specific molecules.4

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].”5 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.”6 In other words, they may be involved — they probably are involved — but the relationship is indirect at best.

The (unknown) cures for delayed onset muscle soreness

A reliable cure for DOMS has yet to be discovered. Among the unconvincing treatments tried are:

Everyone will be pleased to know that one study (predictably European) showed some benefits to hot tubbing, specifically “warm underwater jet massage.”14 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.

The best way to prevent DOMS it is to get it over with.

“Vitamin I” may be partially useful. Ibuprofen (and other anti-inflammatory drugs) have been shown to reduce the pain of DOMS,1516 although — disappointingly — they do not reduce the muscle weakness that goes with it. 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, naturally, the value of anti-inflammatory medication for DOMS has been challenged by other studies that show no benefit to them, and even indicate that there is little or no inflammation present in DOMS.17

Generally speaking, there is a broad consensus that nothing really decisively helps DOMS,1819 and the best way to prevent it is just to get it over with. In other words, only DOMS prevents DOMS!

But what about massage therapy?

Massage and delayed onset muscle soreness

Massage therapists and massage enthusiasts often claim DOMS prevention and cure as a benefit of massage. Unfortunately, there is no convincing evidence to support this, and some that contradicts it.

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.20 Ernst concludes that, “Massage therapy may be a promising treatment for DOMS. Definitive studies are warranted.” That sounds like good news for massage therapy. However, actually reading the paper discouraged me.

Ernst found only seven studies worth considering, and even 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 methodoligical flaws.”

Although I can’t deny that there was some encouragement to be had from the data, it was hardly convincing. I cannot come to the same optimistic-sounding conclusion that Mr. Ernst did.

I remain skeptical that massage therapy can prevent or reduce the intensity of DOMS for most people, most of the time.

Since we don’t know much about what causes DOMS, and we don’t know much about how massage therapy works even when it does21 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 good placebo, if nothing else! — those effects are likely to be limited, and to vary widely depending on the therapist, the individual, and the circumstances.

Therefore, while I agree with Ernst that “definitive studies are warranted,” I remain skeptical that massage therapy can be claimed to generally prevent or reduce the intensity of DOMS, and massage therapy should not be promoted or purchased for this reason. Fortunately, there are many other reasons to have massage therapy: see Does Massage Therapy Work?.


Further Reading

Notes

  1. Pyne DB. Exercise-induced muscle damage and inflammation: a review. Aust J Sci Med Sport. 1994 Sep-Dec;26(3-4):49-58, abstract. Return to text.
  2. Yu JG, Carlsson L, Thornell LE. Evidence for myofibril remodeling as opposed to myofibril damage in human muscles with DOMS: an ultrastructural and immunoelectron microscopic study. Histochem Cell Biol. 2004 Mar;121(3):219-27. Epub 2004 Feb 26, abstract. 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. Return to text.
  3. Malm C, Sjodin TL, Sjoberg B, Lenkei R, Renstrom P, Lundberg IE, Ekblom B. Leukocytes, cytokines, growth factors and hormones in human skeletal muscle and blood after uphill or downhill running. J Physiol. 2004 May 1;556(Pt 3):983-1000. Epub 2004 Feb 06, abstract. 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. Return to text.
  4. 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. The point of citing this evidence is that 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 the idea of “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 a series of 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.” Return to text.
  5. Close GL, Ashton T, Cable T, et al. Eccentric exercise, isokinetic muscle torque and delayed onset muscle soreness: the role of reactive oxygen species. Eur J Appl Physiol. 2004 May;91(5-6):615-21. Epub 2003 Dec 18, abstract. Return to text.
  6. Ibid. Return to text.
  7. Hasson S, Mundorf R, Barnes W, et al. Effect of pulsed ultrasound versus placebo on muscle soreness perception and muscular performance. Scand J Rehabil Med 1990;22: 199–205. Return to text.
  8. Brock Symons T, et al. Effects of deep heat as a preventative mechanism on delayed onset muscle soreness. J Strength Cond Res. 2004 Feb;18(1):155-61, abstract. From the abstract: “Increased muscle temperature [by ultrasound] failed to provide significant prophylactic effects on the symptoms of DOMS.” Return to text.
  9. Rodenburg JB, et al. Warm-up, stretching and massage diminish harmful effects of eccentric exercise. Int J Sports Med. 1994 Oct;15(7):414-9, abstract. Although the title sounds positive, 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 are definitely effective in isolated. Return to text.
  10. Lund H, et al. The effect of passive stretching on delayed onset muscle soreness, and other detrimental effects following eccentric exercise. Scand J Med Sci Sports. 1998 Aug;8(4):216-21, abstract. 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.” Return to text.
  11. Denegar RC, Huff BC. High and low frequency TENS in the treatment of induced musculoskeletal pain: a comparison study. Athletic Training 1988;23:235-7. Return to text.
  12. Weber MD, Serevedio FJ, Woodall WR. The Effects of Three Modalities on Delayed Onset Muscle Soreness. Journal of Orthopedic and Sports Physical Therapy, 1994 Nov;20(5):236-42, abstract. From the abstract: “ …statistically significant differences between massage, microcurrent electrical stimulation, upper body ergometry, and control groups.” Return to text.
  13. 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. Return to text.
  14. Viitasalo JT, Niemela K, Kaappola R, et al. Warm underwater water-jet massage improves recovery from intense physical exercise. Eur J Appl Physiol Occup Physiol. 1995;71(5):431-8, abstract. Return to text.
  15. Hasson SM, Daniels JC, Divine JG et al. Effect of iboprufen use on muscle soreness, damage and performance: a preliminary investigation. Med Sci Sports Exerc 1993;1:9-17, abstract. 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.” Return to text.
  16. Tokmakidis SP, Kokkinidis EA, Smilios I, Douda H. The effects of ibuprofen on delayed muscle soreness and muscular performance after eccentric exercise. J Strength Cond Res. 2003 Feb;17(1):53-9, abstract. 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.” Return to text.
  17. Semark A, Noakes TD, St Clair Gibson A, Lambert MI. The effect of a prophylactic dose of flurbiprofen on muscle soreness and sprinting performance in trained subjects. J Sports Sci. 1999 Mar;17(3):197-203, abstract. From the abstract: “In conclusion, the aetiology of the DOMS induced in the trained subjects in this study seems to be independent of inflammatory processes or, more specifically, of increases in prostaglandin synthesis in the muscles.” Return to text.
  18. Connolly DA, Sayers SP, McHugh MP. Treatment and prevention of delayed onset muscle soreness. J Strength Cond Res. 2003 Feb;17(1):197-208, abstract. 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.” Return to text.
  19. Ernst E. Does post-exercise massage treatment reduce delayed onset muscle soreness? A systematic review. Br J Sports Med. 1998 Sep;32(3):212-4, article. From the article: “An effective treatment has been sought for many years … to date, none of these approaches has been fully convincing.” Return to text.
  20. Ibid. Return to text.
  21. See Does Massage Therapy Work?. Return to text.