AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Hough gave the first detailed description of delayed onset muscle soreness (DOMS) in 1902. DOMS is a widely recognized entity and is experienced by nearly everyone during his/her lifetime. DOMS is defined as the sensation of discomfort or pain in the skeletal muscles following physical activity, usually eccentric, to which an individual is not accustomed. Although DOMS is experienced widely, there are still controversies regarding its origin, etiology, and treatment.

Pathophysiology

Muscle pain mechanism

The sensation of pain in skeletal muscle is transmitted by myelinated group III (A-delta fiber) and unmyelinated group IV (C-fiber) afferent fibers. Both group III and IV sensory neurons terminate in free nerve endings. The free nerve endings are distributed primarily in the muscle connective tissue between fibers, (especially in the regions of arterioles and capillaries) and at the musculotendinous junctions. The larger myelinated group III fibers are believed to transmit sharp localized pain. The group IV fibers carry dull diffuse pain.

The sensation of DOMS is carried primarily by group IV afferent fibers. The free nerve endings of group IV afferent fibers in muscles are polymodal and respond to a variety of stimuli including chemical, mechanical, and thermal. Chemical substances that elicit action potentials in muscle group IV fibers in order of effectiveness are bradykinin, 5-hydroxytryptamine (serotonin), histamine, and potassium.

Etiology and pathophysiology

DOMS results from overuse of the muscle. Any activity in which the muscle produces higher forces than usual or produces forces over a longer time period than usual can cause DOMS. According to Tiidus and Ianuzzo (1983), the degree of muscle soreness is related to both the intensity of the muscular contractions and the duration of the exercise. The intensity seems to be more important in the determination than the duration.

Five hypotheses are used to explain the pathophysiology of DOMS.

• Structural damage from high tension
  
  
  • This hypothesis originally was proposed by Hough and is the most scientifically accepted theory. The delayed pain was related directly to the peak forces developed and to the rate of force development in rhythmic contractions. DOMS was not related to the state of fatigue of the muscle.
  
  
  
  • The rhythmic and tetanic contractions that caused the greatest acute fatigue and discomfort in the muscles during the exercise resulted in the least delayed pain following the exertion.
  
  
  
  • The structural damage is evident in muscles that are not trained for the particular exercise.
     
• Metabolic waste product accumulation
  
  
  • One of the most popular concepts in the lay exercise community is that delayed soreness is a result of lactic acid accumulation in the muscles.
  
  
  
  • The degeneration and regeneration of muscle fibers observed after 2-3 hours of ischemia are similar temporally and quantitatively to the forces resulting from exercise-induced injury.
  
  
  
  • An apparent relationship exists between exercise intensity and the extent of soreness. Much evidence against the metabolic hypothesis also may be noted. The most convincing evidence is that the muscle contractions that cause the greatest degree of soreness require relatively low energy expenditure.
  
  
  
  • Exercise involving eccentric contractions requires lower oxygen consumption and produces less lactate than exercise with concentric contractions at the same power output.
  
  
  
  • Energy use per unit area of active muscle appears to be less in eccentric exercise than in equivalent concentric exercise.
  
  
  
  • Schwane et al tested the metabolic hypothesis and showed that downhill running requires significantly lower oxygen uptake (VO₂) and produced less lactic acid than level running but resulted in greater DOMS.
     
• Increased temperature
  
  
  • Type III and IV nerve endings are sensitive to temperatures of 38-48°C.
  
  
  
  • Elevated temperature could conceivably damage the structural element in the muscle, resulting in necrosis of muscle fibers and breakdown of connective tissues. Eccentric muscle exercise may generate higher local temperatures than concentric contractions. Rhabdomyolysis (extreme of DOMS) is more prevalent in untrained subjects during exercise in the heat.
     
• Spastic contracture
  
  
  • Studies by Travell, Rinzler, and Herman in 1942 and a later series of experiments by Cobb, deVries, and Urban (1975) demonstrated elevated electromyographic (EMG) activity in sore muscles. Altered nerve control and vasoconstriction leads to decrease blood flow and ischemia, which in turn initiates a pain-spasm-pain cycle. The magnitude of pain is dependent upon the number of motor units involved.
  
  
  
  • Other investigators have not been able to detect increased electrical activity in sore muscles.
     
• Myofibrillar remodeling
  
  
  • Recent literature suggests that the myofibrillar and cytoskeletal alterations are considered to be the hallmarks of DOMS and reflect adaptive remodeling of the myofibrils.
  
  
  
  • These include 4 main types of changes: amorphous widened Z-disks, amorphous sarcomeres, double Z-disks, and supernumerary sarcomeres.

Frequency

United States

Incidence of DOMS is difficult to calculate because most people with DOMS do not seek medical attention, and they accept DOMS as temporary discomfort. Every healthy adult most likely has experienced DOMS on countless occasions. DOMS occurs regardless of the person's general fitness level.

Mortality/Morbidity

• Only temporary morbidity is associated with DOMS due to pain and soreness and reduced muscular performance. The diminished performance results both from reduced voluntary effort due to the sensation of soreness and lowered inherent capacity of the muscle to produce force.
• No evidence exists to support that DOMS is associated with long-term damage or reduced function in the muscles. Animal studies indicate that injured muscles regenerate during the period following exercise and that the process essentially is completed within 2 weeks.

Race

No racial predilection is associated with DOMS.

Sex

• Stupka et al (2000) showed that muscle damage following unaccustomed eccentric exercise is similar in both sexes; however, inflammatory response is attenuated in women.



• MacIntyre et al (1996) found different patterns of DOMS and torque between the sexes after eccentric exercise.



• Dannecker et al. in a recent study showed no sex differences were detected except that men reported higher affective ratios than women.

Age

DOMS generally is not reported in children. Adults of all ages can experience DOMS.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• History of heavy unaccustomed exercise, particularly involving eccentric muscle contractions (eg, downhill exercise) is reported.
• The patient complains of pain, soreness, swelling, and a stiff or tender muscle spasm.
• The muscles are sensitive, especially upon palpation or movement.
• Decreased range of motion and reduced strength is noted (especially 24-48 hours postexercise).
• The patient has a sense of reduced mobility or flexibility.
• DOMS begins 8-24 hours after exercise and peaks 24-72 hours postexercise.
• Acute onset muscle soreness begins during exercise and continues for approximately 4-6 hours after exercise.
• The soreness normally increases in intensity during the first 24 hours after exercise and peaks in 24-72 hours, then subsides over the next 5-7 days.

Physical

• The tenderness often is described as localized in the distal portion of the muscle in the region of the musculotendinous junction. According to Newham et al, tenderness within this region could be due to the fact that muscle pain receptors are most concentrated in the region of the tendon and connective tissue in the muscle. Angles of the fibers to the long axis of the muscle are greatest in the region of musculotendinous junction, increasing the susceptibility of the fibers to mechanical trauma.
• In severe DOMS, the pain is generalized throughout most of the muscle belly.
• Swelling of the muscle belly can occur.
• Muscle tenderness is present.
• Decreased muscle strength and flexibility also are noted.

Causes

• Heavy unaccustomed exercises contribute to development of DOMS.
• The exercise involving eccentric muscle contractions results in greater disruption or injury to the muscle tissues than concentric exercise. Thus, any form of exercise with eccentric muscle contractions causes more DOMS than exercise with concentric muscle contractions. Ample evidence from histological studies, electron microscopic examination, and serum enzymes of muscular origin supports this notion.
• To produce a given muscle force, fewer motor units are activated in an eccentric contraction than in a concentric contraction. In eccentric contractions, the force is distributed over a smaller cross-sectional area of muscle. The increased tension per unit of area could cause mechanical disruption of structural elements in the muscle fibers themselves or in the connective tissue that is in series with the contractile elements; however, it has not been proven that injury to muscle cells or connective tissue is the causative factor in DOMS.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Muscle strain or tear
Muscle cramps
Phosphorylase deficiency (muscle soreness after exercise)
Phosphofructokinase deficiency
Carnitine palmityl transferase deficiency
Other types of myopathies

Comparative features of pain during or immediately following exercise, delayed onset muscle soreness, and muscle cramps associated with exercise

	Pain During or Immediately Following Exercise	Delayed Onset Muscle Soreness (DOMS)	Muscle Cramps Associated with Exercise
Etiology	Probable build up of metabolic by-products (include lactic acid, pyruvic acid)	Unaccustomed eccentric exercise	Hyper-excitability of lower motor neuron, possibly related to loss of fluid and electrolytes, and low magnesium level
Onset	During exercise	12-48 hours postexercise	During or after the exercise
Duration/Recovery	Diminish upon termination of exercise and return of normal blood flow	Recovery within 7-10 days	Last usually from a few seconds to several minutes
Type of nerve ending	Type IV free nerve ending	Primarily type IV free nerve ending Type III is also involved	Most likely type III free nerve ending
Type of muscle contraction associated	Sustained or rhythmic concentric and isometric contractions	Unaccustomed eccentricmuscle exercise	Severe, involuntary, electrically active contraction
Treatment	Terminate exercise	Exercise the "sore muscle." No other proven effective treatment	Gentle stretch of the affected muscle Contraction of antagonistic muscle
Prevention	No proven effective preventive measure	No proven effective preventive measure	Stretching the muscles affected may be effective

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Serum creatinine kinase level usually is elevated, but it is nonspecific.

Imaging Studies

• In a study by Dierking et al (2000), diagnostic ultrasound is not sensitive to detect change in muscle cross-sectional area in the diagnosis of DOMS.



• MRI can detect muscle edema in DOMS but is not indicated clinically for the diagnosis. In a prospective evaluation of DOMS, abnormalities found in MRI persisted up to 3 weeks longer than symptoms.

Histologic Findings

• Immediately after the exercise, free erythrocytes and mitochondria may be observed in the extracellular spaces.



• Increase in the numbers of circulating neutrophils and interleukin-1 occurs within 24 hours after the exercise. A prolonged increase in ultrastructural damage and muscle protein degradation occurs, as well as a depletion of muscle glycogen stores.



• Friden et al (1983) observed Z-line streaming within eccentrically exercised muscle fibers that occasionally lead to total disruption of the Z-band area, resulting in disorganization of surrounding myofilaments.



• From 1-3 days postexercise, the period of time when the DOMS is most intense, phagocytes are present in the muscle fibers, and injury to the muscle usually is more apparent.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

Although the relief is temporary, exercise of the sore muscle probably is the best way to reduce DOMS. Muscular soreness does diminish acutely with exercise. Unfortunately, with the cessation of exercise, the soreness returns during the postexercise period, and this cycle continues until the muscle becomes conditioned sufficiently through training. Why exercise decreases DOMS is not clear, although several possibilities exist, including the following:

• Break-up of adhesions from the injured sore muscles takes place during exercise.

• Increased blood flow or temperature in the muscle helps to decrease the accumulation of noxious waste products.

• Endorphin release by neurons in the central nervous system increases during exercise.

• Increased afferent input is noted from large, low-threshold sensory units in the muscles (muscle groups Ia, Ib, and II fibers [gate control theory]).

• Subjects direct attention to the activity and away from the pain.

• Training effect appears to be highly specific, not only for the particular muscles involved in the type of exercise, but also for the type of contractions performed. For example, Schwane and Armstrong found that, in rats, the muscle damage that occurs during downhill running is prevented by downhill or level training but not by uphill training.

Medical Issues/Complications

No evidence exists to support the premise that DOMS is associated with any long-term damage or reduced function in the muscles or any other complications.

Consultations

Consultation with the athletic trainer and the coach may be indicated.

Other Treatment

• Barlas et al (2000) found that acupuncture generally is not effective in the treatment of DOMS; however, another unblinded study by Lin and Yang suggests effectiveness of acupuncture in treating individuals with DOMS.



• Mekjavic et al (2000) concluded that hyperbaric oxygen therapy does not affect recovery from delayed onset muscle soreness.



• Zhang et al (2000) note that a double layer of Farabloc, an electromagnetic shield, wrapped around the thigh has been shown to reduce DOMS.




• Combined low intensity laser therapy was not shown to be effective in DOMS in a study by Craig, Barron, et al (1999). However, a study by Douris et al using 8 J/cm² of phototherapy had shown a beneficial effect (Douris, 2006).




• Pulsed ultrasound therapy (PUS) in one small (6 subjects in each group) randomized double-blind placebo-controlled study by Hasson et al (1999), showed significantly less soreness in individuals treated with PUS. However, in a larger (12 patients in each group) randomized double-blinded placebo-controlled study by Craig, Bradley, et al (1999), no significant benefit from PUS was demonstrated. In a study by Ciccone et al (1991), there was some suggestion that ultrasound may enhance DOMS, but phonophoresis with salicylate may have therapeutic benefits.



• Tourville et al (2006) showed that sensory level-high volt pulsed electrical current was not effective in reducing the measured variables associated with DOMS.




• Transcutaneous electrical nerve stimulation (TENS), in an uncontrolled study by Deneger et al (1992), showed some benefit in relieving the soreness associated with DOMS; however, in a randomized placebo-controlled study by Craig et al (1996), the use of TENS did not show any significant benefit.



• In a small study by Hasson et al (1992), dexamethasone iontophoresis immediately after exercise was shown to decrease muscle soreness perception in DOMS.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

General analgesics and nonsteroidal anti-inflammatory medications have not shown to be effective consistently in many controlled studies.

Oral ascorbic acid (vitamin C) and other antioxidants are also studied for DOMS, with mixed results. A recent study by Connolly et al suggests that a vitamin C supplementation protocol of 1000 mg 3 times a day for 8 days is ineffective in protecting against selected markers of DOMS.

The homeopathic medicine Arnica 30x was studied in a randomized, double-blinded, placebo-controlled study and was found to be ineffective in treating DOMS.

Cannavino et al (2003) showed that transdermal ketoprofen appears to be effective in reducing self-reported DOMS after repetitive muscle contraction, particularly after 48 hours.

Bajaj et al (2003) showed that the prophylactic intake of tolperisone hydrochloride provides no relief to pain in postexercise muscle soreness but results in a reduction in isometric force.

Connolly et al (2006) in a randomized placebo controlled study have shown that tart cherry juice can decrease some of the symptoms of exercise induced muscle damage. Most notably, strength loss averaged over the four days after eccentric exercise was 22% with the placebo but only 4% with the cherry juice.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• No inpatient care is needed for individuals with DOMS.

Further Outpatient Care

• Outpatient care mainly is limited to proper education on specific exercise programs.

Deterrence

• Armstrong (1984) states in his review that there are no preventive measures for DOMS, except for previous specific training of the involved muscle.



• No study has demonstrated that proper warm-up before exercise and cool-down after exercise could help prevent DOMS.



• Johansson et al (1999) discovered that pre-exercise static stretching has no preventive effect on the muscular soreness, tenderness, and force loss that follows heavy eccentric exercise.



• Nonsteroidal anti-inflammatory medications are not effective in preventing DOMS.



• Thompson et al (1997) note that oral contraceptive use attenuates soreness following an exhaustive stepping activity in women, but no association can be drawn between estrogen ingestion and exercise-induced muscle damage.



• Boyle et al (2004) showed that yoga training and a single session of yoga appear to attenuate peak muscle soreness in women following a bout of eccentric exercise. These findings have significant implications for coaches, athletes, and the exercising public, who may want to implement yoga training as a preseason regimen or supplemental activity to lessen the symptoms associated with muscle soreness.

Prognosis

• DOMS can reduce muscular performance temporarily. The diminished performance results both from reduced voluntary effort due to the sensation of soreness and lowered inherent capacity of the muscle to produce force.
• No evidence exists to support that DOMS is associated with long-term damage or reduced function in the muscles.
• Animal studies indicate that injured muscles regenerate during the period following exercise and that the process essentially is completed within 2 weeks.

Patient Education

• The patient needs to be educated on a specific progressive exercise training program before engaging in a heavy unaccustomed exercise, particularly one that involves eccentric muscle contractions.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Sports Injury Center. Also, see eMedicine's patient education article Muscle Strain.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Misdiagnosing DOMS as another muscle pathologic condition can have significant medicolegal consequences.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Apr 6, 2007