Delayed Onset Muscle Soreness...and Massage in Recovery

What is DOMS?

We’ve all experienced that agonizing muscle ache, where there is pain of trying to get out of your car, wobble up the stairs, or move normally after a hard day at work or workouts. This soreness is called delayed onset muscle soreness (DOMS). If you’ve been exercising long enough, you’ve probably felt it. If you've been sitting all day after exercising - you definitely felt it. Some athletes relish this pain as an indicator of success, but is that really the accurate?

I frequently see DOMS occur after a daunting day of activity - with little mental or physical break from one activity. Think six hours in dance class for professional ballerinas, think ANY Iron-man Triathlon. Think of going to the gym before class or work, or bootcamp - and not getting home until 12 hours later. That's a long day... It can also occur in experienced athletes after taking a few weeks off from workouts as part of a recovery.  

A number of treatment strategies have been introduced to help alleviate the severity of DOMS and to restore the maximal function of the muscles as rapidly as possible. Here what aids in the recovery process:

  1. Nonsteroidal anti-inflammatory drugs have demonstrated positive effects based on the dosage. They may also be influenced by the time of use.
  2. Massage has also shown varying results that may be attributed to the time of massage application and the type of massage technique used.

Here is what hasn't worked:

  1. Cryotherapy, stretching, homeopathy, ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms.

Exercise is the most effective means of alleviating pain during DOMS, however the effect if 'active recovery' use as an analgesic is also temporary. Athletes who must train on a daily basis should be encouraged to reduce the intensity and duration of exercise for 1–2 days following intense DOMS-inducing exercise. Alternatively, exercises targeting less affected body parts (think alternate sequence of workouts - upper body, lower body or legs, arms and back or chest,  should be encouraged in order to allow the most affected muscle groups to recover. Eccentric exercises (lengthening under tension and/or weight) or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of, or during, the season in order to reduce the level of physical impairment and/or training disruption. This introduction to activity (10-15% increase) should also be applied when restarting an exercise program. There are still many unanswered questions relating to DOMS, and many potential recovery.

DOMS is Not Fiber Damage

Studies show (1) that DOMs is not restricted to any particular muscle group, but some people tend to experience it more in certain muscles. Technically speaking, DOMS is (primarily) caused by a type 1 muscle strain – some degree of fiber damage, but nothing too serious – predominantly as a result of unaccustomed exercise (either different levels or activities) or long periods of forced inactivity. As you may have experienced, it can range from slight muscle discomfort to severe pain that limits range of motion. Generally, muscle soreness becomes noticeable ~8 hours post-workout and peaks 48-72 hours later, although the exact time course can vary.

There is little doubt that DOMS is correlated with exercise-induced muscle damage to some degree; however, measurement of muscle damage at a microscopic level are poorly correlated with reports of soreness. Basically, if you’re really sore, it doesn’t mean you completely “shredded” the muscles you are feeling soreness in. This is supported by MRI images showing little damage to some muscles post-exercise. Not only do the time cycle, or course of changes that markers of muscle damage indicate, differ from one another, but they also don’t match the time course of muscle soreness (Newham, 1988). It is possible for severe DOMS to develop with little or no indication of muscle damage, and for severe damage to occur without DOMS.

Certain types of exercise can cause significant muscle damage. The image below is taken after an extensive eccentric exercise protocol. As you can see, the muscle fiber just looks messed up. The majority of studies examining exercise-induced muscle injury and DOMS use untrained subjects undertaking large amounts of unfamiliar eccentric exercise. This model is unlikely to closely reflect the circumstances of most people who workout. However, it does give us some insight into what happens in the muscle. (See Image No. 1 below - Image of muscle from an electron microscope after eccentric exercise. Notice the disruption in the muscle pattern).

Another DOMS-inducing stimulus that occurs during exercise is metabolic stress (this does not refer to the buildup of lactic acid, because lactic acid and collagen buildup do not cause DOMS.)  Thinking that lactic acid causes muscle soreness is as inaccurate and dogmatic idea, as the idea that massage gets rid of body toxins.  Viewing by-products of exercise as toxins is outdated and flat-out wrong, after high-intensity exercise, rest alone will return blood lactate to baseline levels well within the normal time period (think 24 hours) between training sessions. However, there is some evidence that hydrogen ions and reactive oxygen species – both of which increase in concentration during exercise – may contribute to DOMS (2). Metabolic stress during exercise can cause changes on a structural level at the cell membrane (sarcolemma). The damage allows fluids and other factors to enter the cell, which promotes inflammation (3).

Cell swelling occurs during exercise-induced muscle damage when fluid and plasma proteins can exceed the capacity of the drainage. The result is edema in the muscle, with significant swelling lasting ~48 hours post-exercise.

Does DOMS mean more muscle growth?

Some studies show the presence of DOMS after long-distance running, which indicates it doesn’t just occur during resistance training. This should be an anecdotal sign that DOMS isn’t a good gauge of muscle growth, because running causes minimal hypertrophy - and there may indeed be DOMS after long distance endurance races.

People who are new to working out often have the most pronounced DOMS. They also happen to grow the most, so you can see how the two may be intertwined. This is due to the new stimulus that exercise provides. Again, they get sore because they aren’t accustomed to exercising – not because they are growing like monsters. Interestingly, there is no difference in DOMS between sexes even for beginners.

There is some evidence to show DOMS may negatively affect workouts by altering motor patterns in subsequent workouts. This could cause reduced activation of the desired muscle. Hence, DOMS could actually hinder your next workout. In addition, severe DOMS can decrease force capacity by up to 50% (6). This causes functional deficits that may impair training at a certain level, which could hinder muscle growth in the long term.

Exercising while having DOMS does not seem to make muscle damage worse (7), but it may interfere with the recovery process. In extreme cases, exercise-induced muscle damage can cause rhabdomyolysis, a serious condition that can lead to renal failure. So be careful when throwing a newbie into an advanced program – especially if they’ve never exercised. You could do some serious damage.

”The “No pain, No gain” theory is wrong – at least for muscle growth.” 

How do I feel DOMS?

Nociceptor

So if you aren’t destroying your muscles or burning them up with lactic acid, then why do they hurt? I recently discussed this concept with a member of my lab.

Nociceptors are free nerve endings that respond to damaging stimuli by sending pain signals to the brain. In muscle tissue, these receptors can sense chemical stimuli such as inflammation or disturbances in microcirculation to blood vessels. These receptors are not inside the muscle because muscle cell death is not painful. In comparison, tearing a muscle can be extremely painful. The pain is due to the release of muscle substrates into the space where nociceptors are located. This also helps us appreciate that DOMS probably doesn’t occur due to something inside the muscle (i.e., in the contractile apparatus) (7).

How can I reduce DOMS?

One of the best ways to decrease the risk of DOMS is to slowly progress into a new exercise program. If you’ve ever had an advanced program, you’ll notice the first week or two may have reduced volume. The “prep” phase of programs has two purposes: 1) allowing the muscle time to acclimate to a new movement, and 2) leaving room for more adaptation.  

We all know we should warm-up properly. This is probably one of the only times you’ll hear it doesn’t help. While it may prepare you for exercise (I highly suggest it), neither warming up nor stretching before exercise has been shown to reduce or prevent DOMS.

Something a lot of people use to relieve DOMS is foam rolling. However, it has only been shown to improve DOMS in some studies. During foam rolling, you use your own body mass on a foam roller to exert pressure on an area of soft tissue. The motion places direct pressure on an area, which stretches it. It is considered self-induced massage because the pressure somewhat resembles the pressure exerted on muscles by a massage therapist. Again, there are only a few studies that have measured the effects of foam rolling on performance. These studies found foam rolling can enhance recovery after DOMS and alleviate muscle tenderness. Self-massage through foam rolling could benefit people wanting to recover in an affordable, easy, and time-efficient way.  

Another intervention commonly used is massage. Some researchers have shown decreases in pain associated with DOMS after a massage (8). However, massage has no effect on muscle metabolites such as glycogen or lactate. One study found massage decreased the production of the inflammatory cytokines by mitigating cellular stress resulting from muscle injury (8). Many people believe massage can provide increased blood flow to specific areas, reduced muscle tension, and mood enhancement. Massage produces direct pressure, which may increase ROM and stiffness. These benefits are expected to help athletes by enhancing performance and reducing injury risk.  The effects of timing of massage (pre- or post-exercise) on performance, injury recovery, or injury prevention are not clear because the mechanisms of each massage technique have not been widely studied.

Supplements to reduce DOMS

Caffeine has long been known to increase alertness and endurance, shown by the the average person’s morning grumpiness before drinking the black gold. Interestingly, a recent study by Hurley et al., reported caffeine has the ability to reduce DOMS. They mesured perceived soreness in males consuming caffeine one hour before a workout. They found a lower level of soreness in the biceps on day 2 and 3 compared to a placebo after subjects completed a bicep curl protocol.  Using a dosage of 5mg/kg bodyweight they found a beneficial effect of caffeine on soreness. For comparison, a 185lb (~84kg) male would take about 420mg of caffeine preworkout. That is a ton of caffeine! An 8oz Red Bull contains roughly 85mg. Does your preworkout supplement have that much caffeine? Probably not. If you’re wondering when caffeine peaks in the blood, it’s about one-hour post ingestion. Caffeine is an adenosine antagonist and affects the activity of central nervous system (CNS) by blocking adenosine receptors, thus resulting in decreased levels of soreness. This suggests that short-term caffeine ingestion before a strenuous workout may decrease overall soreness levels.  However, the subjects who took caffeine were able to perform more reps than the control group, which could be a confounder.

Taurine is found in muscle and has multiple biological functions. Remember that Red Bull I mentioned earlier? Well, it has about 1,000mg of taurine. For reference: Up to 3,000mg a day of supplemental taurine is considered safe. One double-blind study (10) of males completed over 21 days measured the effects of 50mg of taurine (20x less than the content in a Red Bull) after 7 days of eccentric exercise.  The researchers found a reduction in DOMS and oxidative stress markers after exercise; however, there was no effect on inflammatory markers. Could this be a way to battle the other side? If inflammation is one component to DOMS and oxidative stress is another component, we need a study to combine the two. That probably won’t happen soon, but it would be fun to see if they were synergistic.

Omega-3 fatty acid is found in fish and is becoming increasingly used tofortify foods. You can also find EPA/DHA in those lovely pills that make you burp fish all day. Several studies reported positive effect of omega-3 fatty acids on DOMS, presumably due to the decrease in pro-inflammatory factors such as IL-6 and TNF-alpha. There are a ton of studies to show taking an omega-3 supplement is good for you in many ways, and this seems to hold true for DOMS. If you’re interested in the results, the main table from Jouris et al 2013is below.

Manual Therapy to reduce DOMS

y, on the other hand, Cryotherapy probably doesn’t reduce DOMS.  This goes directly against the current trend of athletes jumping in a tube surrounded by liquid nitrogen to help recovery. Whole body cryotherapy exposes athletes to cold, dry air below -100C for between two and four minutes in a specialized chamber. A recent Cochrane Review by Costello et al., found that there was insufficient evidence to determine whether cryotherapy can reduce muscle DOMS or improve recovery.  

No guidelines currently exist for its clinical effectiveness or for safe usage. Cryotherapy is thought to work by reducing  temperature in the skin, muscle, and core. The theory is muscle soreness is relieved by reducing muscle metabolism, skin microcirculation, nerve conductivity and receptor sensitivity. In addition, it could have a placebo effect by reducing the subjective feeling of DOMS post-exercise. Using a meta-analysis based on four eligible studies, it seems cryotherapy does not reduce DOMS or improve recovery. Furthermore, insufficient evidence exists on whether this therapy could actually be harmful.  We do know, however, that cold water emersion post-exercise can decrease rate of muscle growth. For the time being, cryotherapy and cold water emersion are probably two things you should avoid – you probably won’t recover any faster, and you may not build as much muscle.

2) Neuromuscular Massage, is a consistent deep tissue treatment which aims to release muscle adhesion at the source - the neuromuscular endplate. It can be painful, it can be time consuming - and if you use it during training, you may have to plan it for the off days where you have nothing else going on. It actually changes the proprioception or spacial orientation of the muscles. Athletes report 'having more space, more flexibility and greater capacity.' Since a lot of this is in the mind, if you've been training within specific parameters for a big race, you know how your body functions - once you make these changes you have to dial it into your mind as well. Hurdler's are a very specific example - if you know exactly how much hip flexion it takes to get over a hurdle, and after an NMT appointment you have "way more stride," it's going to through you off.

3) Active Release Techniques, is another deep tissue technique which aims to release muscle adhesion, realign muscle fibers and can be uncomfortable. But it is a much quicker and less of a change to the proprioception wherever it is used. Made famous by chiropractors, this technique actually takes muscles through a stretch (both active and passive), where the body is guided back to length, strength and done with full knowledge of the brain (hence the active). The client is shown, talked through and is participating in the treatment - so that by the end of the time, they know how much change has taken place. Although there can be significant changes, the awareness around the movements doesn't progress from total relaxation to 'realignment' within 24 hours. The reset is immediate - and there is minimal change to the parasympathetic nervous system, and there is no catch-up time to the brain.

Conclusion

Soreness can provide some insight, but don’t use it as a marker for a good workout. High levels of soreness indicate the athlese has exceeded the capacity for the muscle to undergo repair. Indeed, soreness can impede the ability to train properly, and it may decrease motivation.

The consensus among researchers is that there is no single component that causes DOMS. Instead, there are a number of complex events that may explain this phenomenon. It is the main cause of reduced exercise performance including decreased muscle strength and range of motion for both athletes and non-athletes. A combination of all the post-workout recovery tools, is probably a good idea to see what works for you as an individual.

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