eMedicine Specialties > Physical Medicine and Rehabilitation > Muscle Pain Syndromes

Postexercise Muscle Soreness: Differential Diagnoses & Workup

Author: Divakara Kedlaya, MBBS, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Coauthor(s): Timothy Kuang, MD, Pain Management Fellow, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Contributor Information and Disclosures

Updated: Jun 6, 2008

Differential Diagnoses

Acute Poliomyelitis
Myofascial Pain
Postpolio Syndrome

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

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Table
Pain During or Immediately Following ExerciseDelayed Onset Muscle Soreness (DOMS)Muscle Cramps Associated with Exercise
EtiologyProbable buildup of metabolic by-products (include lactic acid, pyruvic acid)Unaccustomed eccentric exerciseHyperexcitability of lower motor neuron, possibly related to loss of fluid and electrolytes, and low magnesium level
OnsetDuring exercise12-48 hours postexerciseDuring or after the exercise
Duration/RecoveryDiminishes upon termination of exercise and return of normal blood flowRecovery within 7-10 daysLasts usually between a few seconds and several minutes
Type of nerve endingType IV free nerve endingPrimarily type IV free nerve ending
Type III is also involved.		Most likely type III free nerve ending
Type of muscle contraction associatedSustained or rhythmic concentric and isometric contractionsUnaccustomed eccentric muscle
exercise		Severe, involuntary, electrically active contraction
TreatmentTerminate exercise.Exercise the "sore muscle." No other proven effective treatmentGentle stretch of the affected muscle
Contraction of antagonistic muscle
PreventionNo proven effective preventive measureNo proven effective preventive measureStretching the affected muscles may be effective.
Pain During or Immediately Following ExerciseDelayed Onset Muscle Soreness (DOMS)Muscle Cramps Associated with Exercise
EtiologyProbable buildup of metabolic by-products (include lactic acid, pyruvic acid)Unaccustomed eccentric exerciseHyperexcitability of lower motor neuron, possibly related to loss of fluid and electrolytes, and low magnesium level
OnsetDuring exercise12-48 hours postexerciseDuring or after the exercise
Duration/RecoveryDiminishes upon termination of exercise and return of normal blood flowRecovery within 7-10 daysLasts usually between a few seconds and several minutes
Type of nerve endingType IV free nerve endingPrimarily type IV free nerve ending
Type III is also involved.		Most likely type III free nerve ending
Type of muscle contraction associatedSustained or rhythmic concentric and isometric contractionsUnaccustomed eccentric muscle
exercise		Severe, involuntary, electrically active contraction
TreatmentTerminate exercise.Exercise the "sore muscle." No other proven effective treatmentGentle stretch of the affected muscle
Contraction of antagonistic muscle
PreventionNo proven effective preventive measureNo proven effective preventive measureStretching the affected muscles may be effective.


Workup

Laboratory Studies

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

Imaging Studies

  • In a study by Dierking and colleagues, diagnostic ultrasonography, when used in the diagnosis of DOMS, was not sensitive enough to detect changes in a cross-sectional muscle area.10
  • Magnetic resonance imaging (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 did symptoms.

Histologic Findings

  • Immediately after 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 exercise. A prolonged increase in ultrastructural damage and muscle protein degradation occurs, as well as a depletion of muscle glycogen stores.
  • Friden and colleagues observed Z-line streaming within eccentrically exercised muscle fibers that occasionally led to total disruption of the Z-band area; this resulted in disorganization of surrounding myofilaments.11
  • From 1-3 days postexercise, the period of time when DOMS is most intense, phagocytes are present in the muscle fibers, and injury to the muscle usually is more apparent.

More on Postexercise Muscle Soreness

Overview: Postexercise Muscle Soreness
Differential Diagnoses & Workup: Postexercise Muscle Soreness
Treatment & Medication: Postexercise Muscle Soreness
Follow-up: Postexercise Muscle Soreness
References
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References

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Further Reading

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Keywords

postexercise muscle soreness, delayed-onset muscle soreness, DOMS, post-exercise muscle soreness, muscle overuse, rhabdomyolysis, metabolic waste product accumulation, spastic contracture, myofibrillar alterations, cytoskeletal alterations

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Contributor Information and Disclosures

Author

Divakara Kedlaya, MBBS, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Divakara Kedlaya, MBBS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Timothy Kuang, MD, Pain Management Fellow, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Timothy Kuang, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Curtis W Slipman, MD, Director, University of Pennsylvania Spine Center, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center
Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, and North American Spine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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